Insurance Plans India 1019 views October 31, 2020

United India Workmen Medicare Policy

You can buy a health insurance policy from United India Insurance Company Ltd. And if you are covered under the United India Workmen Medicare Policy, you would be liable under the Workmen’s Compensation Act, 1923, for the payment of compensation in the event of bodily injury caused due to an accident during and in the course of employment. Only if the injury requires hospitalization expenses for medical or surgical treatment in India as an inpatient upon the advice of a duly qualified Physician, Medical Specialist, Medical Practitioner, or a qualified Surgeon to incur, the company will pay the same through TPA to the Hospital or Nursing Home.

The claim amount does not exceed the Sum Insured for each Insured person in any one period of insurance as stated in the policy schedule. Read this post and know the United India Workmen Medicare Policy coverage and exclusions.

Coverage of United India Workmen Medicare Policy

The company provides coverage to the insured person under United India Workmen Medicare Policy for the following:-

  1. Room Boarding Expenses of Hospital or Nursing Home Limit up to 1% of the sum insured per day. And this includes Nursing care, RMO charges, IV Fluids, Blood Transfusion, Injection, administration charges. It does not include the cost of materials used in the Hospital or Nursing Home.
  2. ICU Charges are up to 2% of the sum insured per day
  3. Surgeon, Anaesthetist, Medical Practitioner, Consultant, or any Specialist’s fee
  4. Anaesthesia, Blood, Oxygen, Operation Theatre (OT) Charges
  5. Surgical Appliances
  6. Medicines and Drugs
  7. Diagnostic Material
  8. X-Ray
  9. Artificial Limbs
  10. Ambulance Charges not exceeding INR 2,500 per person per event

The policy compensation is payable to the insured under Workmen’s Compensation’s Act, 1923, for the injury. The liability of employers towards employees of contractors is covered unless specifically declared in the policy.

Exclusions from the United India Workmen Medicare Policy

There are a few expenses that the Company shall not be liable to pay under this policy. Check out below which are those expenses.

  1. Injury due to an accident which is directly attributable to war, war like operation, and another convulsion of nature. This also includes nuclear fuel or material that is contaminated by radioactivity.
  2. Pneumoconiosis caused by chlorogenic mineral dust (silicosis, anthracosilicosis, asbestosis) and silico-tuberculosis as silicosis is an essential factor in causing the resultant incapacity or death.
  3. Bagassosis
  4. Bronchopulmonary diseases (it is caused by cotton, flax hemp and sisal dust, also known as Byssinosis)
  5. Extrinsic allergic alveolitis (it is caused by inhalation of organic dust)
  6. Bronchopulmonary (it is caused by hard metals)
  7. Acute Pulmonary Oedema (of High Altitude Only).
  8. If an injury or disablement directly or indirectly arising out of or contributed to any existing disability on the date of this policy issuance.
  9. If the injury is intentional like suicide, or attempted suicide (either you are under the influence of intoxicating liquor or drugs)
  10. Insanity
  11. Injury due to criminal intent
  12. If the bodily injury is caused by any accident other than arising out of and in the course of employment
  13. Vitamins and tonics expenses (unless prescribed for the treatment by attending medical practitioner)
  14. Naturopathy Treatment

Claim Procedure of United India workmen Medicare Policy

To raise a claim, you need to submit a Claim Form in the required format with the following documents:

  1. Attested copy of F.I.R. or a Panchnama
  2. Newspaper cuttings (if applicable)
  3. Photographs if any
  4. Original hospitalization or nursing home bills
  5. Discharge certificates, receipts, cash memos, prescriptions, X-rays, pathological reports
  6. Certificate from the attending physician stating the nature and extent of the injury
  7. Any additional information and assistance (if the company requires)
  8. Employment proof like an employer-employee relationship, and attested copy of attendance register.
  9. Salary Payment
  10. And Disbursement Register

If any claim becomes admissible under this scheme, the company will pay to the Hospital, Nursing Home, or the insured person through TPA. If you have a reasonable cause to show, you should do within one calendar month after the event that gives rise to a claim under the policy. You must submit full particulars with all the supporting documents of the claim and seek reimbursement.

When Will the Claim be Rejected?

Below are the following situation where your claim request can be rejected:-

  1. The sum insured is not payable if an employee is not a workman within the meaning of laws
  2. You aren’t able to get your sum insured if any liability of the Insured which attaches by an agreement but not attached in the absence of such agreement.
  3. If the sum is entitled to recover from any party from which you have borrowed money from in an agreement with such party.
  4. The reimbursement will not be payable for expenses incurred for diseases mentioned in part c of the schedule – III of the WC Act, 1923.

What are the United India workmen Medicare Policy Cancellation Clause?

At any time, the insurer can cancel this policy on grounds of misrepresentation, fraud, nondisclosure of a material fact, or non-cooperation by the insured by giving a 15-day notice period in writing via a registered address to the insured as per his/her last known address. In such a case the company returns a proportion of the last premium corresponding to the unexpired period of insurance to the insured ( if no claim has been paid under the policy ). The insured can also cancel the policy any time, and in such an event, the company will give you a refund of premium at the company’s short period rate table shown below:

Period of Cancellation Risk Rate on Premium
Up to one month1/4th of the annual rate
Up to three months1/2 of the annual rate
Up to six months 3/4th of the annual rate
Exceeding six monthsFull annual rate

United India workmen Medicare Policy Renewal

To renew the United India workmen Medicare Policy, your renewal premium shall be paid to the company on or before the expiry date. As the company is not bound to give you notice of renewal premium, provided if the insured applies for renewal and remits the requisite premium before the expiry, renewal may not be refused, except for moral hazard, fraud, misrepresentation, and any other reason where the company has a reasonable justification.

Terms & Conditions for United India Workmen Medicare Policy

  1. Every notice or communication must be delivered in writing at the company address as shown in your policy schedule. In any event like a claim request under this policy, you will forthwith give notice thereof to the company.
  2. The premium for this policy would be paid in advance
  3. No receipt for premium is valid except for the official forum of the company signed by a duly authorized official
  4. Due premium and the observance and fulfillment terms, provisions, conditions, and endorsements of the policy by the insured, so far relate to anything that is done or compiled by the insured in a condition precedent to any liability of the company to make payment for the policy.
  5. The Insured Persons shall allow any representative of the company to examine the injury either at their home residence, Hospital, or Nursing Home. And you should cooperate with the company if any claim reduction measures are suggested.
  6. If a claim in any manner fraudulent or supported by any fraudulent statement or device, whether by the Insured or Insured Person or by any person acting on their behalf, it will get rejected.
  7. Your policy will be void and all paid premium hereon shall be forfeited by the company in the event of misrepresentation, misdescription, or non-disclosure of any material facts or particulars.
  8. When any difference arises to the quantum need to be paid under this policy, such difference shall independently of all other questions be referred to the decision of an appointed sole arbitrator. If there is no agreement reached upon by a single arbitrator within 30 days, the same shall be referred to a panel of three arbitrators. The panel comprises two arbitrators, one to be appointed by each of the parties to the dispute or difference. And the third arbitrator is appointed by the two such arbitrators. The arbitration is conducted under and by the provisions of the Arbitration and Conciliation Act 1996.
  9. No difference or dispute will be referable to arbitration as provided if the company has disputed or not accepted liability. It is stipulated and declared that the condition precedent to any right of action or suit upon this policy that the award by such arbitrator or arbitrators of the amount of the loss or damage will be first obtained.
  10. If a company disclaims liability to the insured for any claim herein under, and such claim shall not, within 12 calendar months from the date of such disclaimer have been paid, the subject is a matter of a suit in a court of law. The claim for all purposes later will be deemed and have been abandoned and thereafter will not be recoverable.
  11. All medical and surgical treatments under United India workmen Medicare Policy shall be taken in India only and the admissible claims are payable in Indian National Rupee (INR) currency.
  12. If in respect of the covered expenses, there is any other insurance of any nature that covers the same, whether effected by the Insured or not, the company will not be liable to pay or contribute more than the rateable proportion of any loss or damage.
  13. Due observance and fulfillment of the policy terms conditions and endorsements are so far related to anything that needs to be done by the insured and the truth of this statement and the answers in the proposal form shall be conditions precedent to any of the liability of the company for payment under United India workmen Medicare Policy.

NOTE: No waiver of any terms, provisions, conditions, and endorsements of United India workmen Medicare Policy is valid unless it is made in writing and signed by an authorized official of the company. The waiver of this condition may be considered in extreme cases of hardship where it is proved to the satisfaction of the insurer that under the circumstances the insured is unable to give such notice or file a claim within the prescribed time-limit.

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