2 - Health Insurance Flashcards
What is personal accident and sickness insurance?
Personal accident and sickness (PAS) insurance pays fixed benefits if the insured suffers an accident or is off work due to sickness.
Why are personal accident insurance contracts not contracts of indemnity?
Because they seek to provide a sum that is fixed in advance for certain specified events.
What are the basic policy features for Personal accident and sickness insurance:
- PAS insurance can be bought as a stand-alone policy but is often purchased as an ‘add on’ to travel, motor, or household insurance.
- Policies are issued on an annual basis and must be renewed each year. This means that the underwriter can decline further cover if the claims experience during the year has been poor.
- The occupation of the proposer is the main rating factor for the personal accident element.
Main points to consider for the definition of ACCIDENT within a PAS policy:
- Identifiable cause (an accident);
- Fortuitous (unintentional);
- A time limit is set between the accident and the event insured (e.g. death or a form of disablement); and
- Sometimes policies specify that no other cause must contribute to the death or disablement resulting from the original bodily injury.
How the accident cover is paid?
- Capital lump sum are paid in the event of death or certain specified injuries.
- The policy usually provides weekly benefit of up to 104 weeks.
- In the event of permanent total disablement, either a capital sum or, less commonly, a ten-year annuity is paid.
What benefit sickness cover provide?
The sickness section of a PAS policy provides a weekly benefit for up to 104 weeks, if the insured is temporarily and totally disabled from engaging in their usual occupation due to sickness or disease
What is mean by time franchise?
This benefit is normally subject to a time franchise, meaning that for the first seven days of disablement, no payment is made. But, if the sickness extends beyond this, the claim is paid for the whole period, including the first seven days.
What period is excluded for sickness cover?
The cover generally excludes sickness contracted within the first 21 days of commencement of the policy period.
What is covered under PAS?
- Death (the death must occur within 12 months of the event. Capital benefits can range from £20,000 to £150,000).
- Total loss of (sight in) one or both eyes ( A typical capital sum payable is £20,000)
- Total loss of one or more limbs (A capital sum is paid, typically around £20,000, regardless of how many limbs are lost. The event must occur within 12 or 24 months of the accident occurring).
- Permanent total disablement (A typical capital sum is £20,000. The decision about whether disablement is total isn’t usually made until 12 or 24 months after the accident)
- Permanent partial disablement (This cover relates to the loss of identified parts of the body but not whole limbs and is usually based on a stated percentage of the sum payable for loss of entire limb)
- Temporary total disablement (If an insured is temporarily unable to engage in their usual occupation due to accident or sickness, a weekly benefit of say £200 will be payable, for a maximum of 104 weeks)
- Temporary partial disablement (The amount is traditionally set at a level of 40% of the temporary total disablement figure)
- Medical expenses
- Legal expenses ( cover for, say, £15,000)
What is geographical limit for:
- Accident Cover
- Sickness cover
- Worldwide
2. UK, Europe, USA, Canada, Australia and New Zealand
What are the age limits for:
- Accident Cover
- Sickness cover
- Age 16 - 70
- 16 - 60 ( Some policies will increase the age limit for children in full time education up to age 23, where they are living with or dependent on the main policyholder.)
What are the Exclusions for PAS?
- The insured being under the influence of, or being affected by, alcohol or drugs, unless under medical supervision;
- Self-inflicted injury or disease;
- Pre-existing physical disabilities;
- Childbirth, pregnancy, venereal disease or AIDS;
- The insured engaging in certain sports and pastimes, although some insurers will cover them for an additional premium; for example polo, winter sports and motorcycling;
- Sickness occurring within 21 days of the policy being taken out; and
- War risks.
What cover is provided under Medical expenses insurance?
Medical expenses insurance covers private medical treatment outside the NHS, giving an individual a choice of specialist consultant, hospital and timing of treatment.
What Inpatients’ cover is provided under medical expenses insurance?
- Hospital charges ( Consultations, theatre fees and dressings)
- Specialist fees (Surgeons’ and anaesthetists’ fees)
- Additional costs (Ambulance and nursing fees)
