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1. What is the claim process of ICICI Prudential Life Insurance Company?

We have a 4 Step claim process

• Claimant to intimate ICICI Prudential Life about the claim
• ICICI Prudential Life to inform the claimant to complete the documentation for faster claim processing
• Claimant to submit the required documents
• ICICI Prudential Life to take decision on the claim

2. What parameters are considered by the company while asking the claimant to submit particular records/ documents?

The company considers the cause, circumstances of claim and duration of the policy while asking for requirements e.g. For accidental death, specific proofs such as post-mortem and police report are required whereas for death due to an illness, the company calls for records from hospital, test reports etc.

3. How can a claim be intimated to the company?

Claim can be communicated through

Written Intimation

• Nearest ICICI Prudential Life branch/Corporate Claims Cell

Verbal Intimation*

• SMS IClaim<space>8 digit policy no to 56767
• Contact number 1860-266-7766
• E-mail at lifeline@iciciprulife.com 

* Kindly note that claim will be formally registered only after receipt of written intimation at branch/ Corporate Claims Cell

4. Why is it essential to produce all the records/ documents as required by the company?

Claims are examined and settled by the company on the basis of all records and proofs in connection with the claim. On notification of a claim, the company informs the claimant about the required documentation. For faster claims processing, we advise early and complete submission of required documents.

Our officials can be contacted for any clarification/ assistance with regard to the claim.

5. Where can a claimant get claim forms and list of documents required for submission?

The claimant can get the claim intimation form

• In the policy document as a part of our welcome kit
• At the nearest ICICI Prudential Life Insurance Co. branch
• From our advisor
• In our website under claims section

6. Where can the claimant submit claim documents?

The claimant can submit the documents at

• Nearest ICICI Prudential Life Insurance Co. branch
• Life claims cell/Health claims cell

        ICICI Prudential Life Insurance Company Ltd,

        BSEL tech, C- wing, 1st floor,

        Vashi, Navi Mumbai – 400703

7. What is the time frame within which the claim has to be reported to the company?

A claim must be reported as soon as possible to enable the company to process the claim, however, for disability claim the company has stipulated period of 120 days from the date of disability and for critical illness and major surgery claim the company has a stipulated period of 60 days from the date of diagnosis/ surgery respectively.

8. Once all the requirements are submitted, how long does it take for the company to settle the claim?

The company settles the claim within 10 working days after all the records, documents and necessary forms are submitted and the documentation is completed. In case the claim warrants further verification, the company keeps the claimant informed of the same. Subsequently, when a decision is taken, it is communicated to the claimant by means of a letter.

9. Who is entitled to receive the claim benefit?

• The nominee or the appointee (in case of minor nominee) last recorded under the policy in case of policy on own life
• The proposer in case the policy is not on own life
• Assignee in case the policy is assigned
• Life Assured himself/ herself in case of policy on own life for living benefit claims i.e. claims under disability, critical illness and major surgery rider

10. What is the procedure when there is no nomination or in case of pre-deceased nominee at the time of death claim?

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 claim would be paid to the person specified in the said proof. If the company has accepted the claim 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.

11. How will the claimant receive the claim amount?

The company honours claim payments through cheque or ECS as per the convenience of the claimant.

Cheque Payments:

• A cheque is drawn on ICICI Bank
• It is dispatched directly to the claimant at the address mentioned in the intimation form/ claimant’s statement
• In non-serviceable areas the cheque is sent to the local branch with an instruction to forward it to the claimant

Electronic Clearing Service:

• ECS mandate along with cancelled cheque needs to be submitted
• Funds will be transferred directly to the claimant’s bank account

12. Under what circumstances is a claim declined by the company?

A claim will be declined if the claim made does not comply to

• Declaration & Authorization agreed at the proposal stage in the application form
• Terms & Conditions provided in the policy document

13. How does a claimant communicate his/ her concerns in connection with a claim decision?

The company has a Grievance Redressal Committee that is chaired by an external member. If the claimant wishes to represent his or her case, a letter addressed to the committee can be sent at the address given below.

Grievance Redressal Committee (Chaired by external member)

ICICI Prudential Life Insurance Company Limited,

Fourth Floor, Stanrose House, ICICI Venture Building

Appasaheb Marathe Marg, Prabhadevi

Mumbai - 400025

Considering all the facts and circumstances, the committee takes a decision on every representation.

14. What is the communication address of the claims department?

A written communication can be sent either to the concerned branch or can be sent directly to the following address:

Life claims cell/Health claims cell

ICICI Prudential Life Insurance Company Ltd,

1st Floor, Vinod Silk Mills Compound,

Chakravarthi Ashok Nagar,

Ashok Road, Kandivili (E),

Mumbai - 400 101.

Comp/doc/Dec/2008/891

RIDERS

1. What riders are offered by the company?

Accident and Disability Benefit Rider (ADBR)*

• Death and living benefit rider
• On death due to an accident 100% of the rider sum assured is given to the policyholder in addition to the basic plan sum assured
• On death due to an accident in a land surface mass public transport system, where the policy holder was traveling as a fare paying passenger 200% of the rider sum assured is given to the policy holder in addition to the basic plan sum assured
• On permanent disability 10% of the rider sum assured paid annually for the next 10 years or till the date of maturity which ever is earlier. Waiver of premium in the basic plan sum assured is limited up to the rider sum assured. Further 100% maturity benefit under the basic plan sum assured is available on completion of the term
• 1st installment falls due on 1st anniversary of the disability date. In the event of unfortunate death of the Life Assured or on the maturity of the policy, whichever is earlier, the balance installments if any, are paid in lump sum
• In case of endowment policy, the premium for the basic cover equal to the sum assured under this rider is waived. The balance premium if any, including premium for other riders such as critical illness would be payable by the policyholder in order to keep the policy in force. The waiver starts with effect from that premium due date which is immediately after the date of disability

Accident Benefit Rider (ABR)*

• Death benefit rider
• On death due to an accident 100% of the rider sum assured is given to the policy holder in addition to the basic plan sum assured. If the death occurs due to an accident in a mass transport communication 200% of rider sum assured is not payable

Waiver of Premium Rider (WOPR)*

• Living benefit rider
• In case of total and permanent disability as a result of accident, the premium under the policy equal to the cover amount under this rider is waived
• The waiver starts with effect from that premium due date which is immediately after the date of the disability

Income Benefit Rider (IBR)*

• Death benefit rider
• 10% of sum assured is payable annually to the nominee child/appointee on each policy anniversary following death of the life assured till maturity of the policy

Critical Illness Benefit Rider (CIBR)*

• Living benefit rider
• On contracting any 9 critical illnesses, (i.e. cancer, coronary artery by-pass graft surgery, heart attack, kidney failure, major organ transplant, stroke, paralysis, aorta surgery, heart valve replacement/surgery)* the rider claim is paid out and the base policy continues
• There are 2 benefits available
  1. Accelerated - On contracting any of the above critical illness the policy holder is given the accelerated basic plan's maturity benefit. The rider claim is paid out and the policy is cancelled along with the riders
  2. Standalone - The rider claim is paid out and the base policy continues

Major Surgical Assistance Benefit (MSAR)**

• Living benefit rider
• There are 43 surgical procedures that are covered in this rider
  1. Major procedures - 50% of the rider sum assured is paid
  2. Intermediate procedures - 30%of the rider sum assured is paid
  3. Minor procedures - 20% of the rider sum assured is paid
  4. The maximum cap is only up to 50% of the rider sum assured

Level Term Assurance Benefit (LTAR)**

• Death benefit rider
• Since it is an additional benefit, the nominee will be getting the additional sum assured of the rider along with the basic plan sum assured
• This rider provides additional life cover for the term of the rider or the term of the basic plan, whichever is less

*For detailed list of benefits/ exclusions/ conditions, please read our sales brochure before concluding sale.

**Company has discontinued offering MSAR and LTAR riders.

2. What are the accident covers available?

As a company, we provide death benefit which is known as basic cover. This cover is payable irrespective of cause of death. The only exclusion is suicide committed by the life assured within first year of issuance of the policy. Additionally, a specific cover for accident can be attached to the basic cover in the form of riders at an additional premium. Currently the company offers following accident riders:

• Accident and Disability Benefit Rider (ADBR) provides benefit in the event of accidental death or accidental disability
• Accident Benefit Rider (ABR) provides benefit in the event of accidental death only
• Waiver of Premium Rider (WOPR) provides benefit in the form of premium waiver in case of accidental disability
  

3. Definition of 'Disability' as per policy document

Definition of 'Total and permanent disability' as per the policy

• Disability must be as a result of an accident or injury caused by violent, external and visible means
• Accident or injury resulting to loss by physical separation of any two limbs (arm or leg) or loss by physical separation of one limb coupled with permanent loss of vision in one eye or permanent loss of vision in both the eyes
• Disability suffered must be total and permanent in nature and continuous for six consecutive months, rendering the life assured unlikely ever of gainful employment. This will be determined by the company after evaluation and verification

4. What are the conditions for accident/ disability riders?

• The policy must be in force on the date of accident
• The death or disability must occur within 180 days of the accident
• The benefit is available only till the life assured is 65 years of age

5. What are the situations (exclusions) under which accident benefit is not payable?

• Accident due to self-inflicted injuries or death by committing suicide
• Life Assured driving under the influence of drugs / liquor at the time of accident
• Accident in case of aerial flights other than as a fare paying passenger on a licensed passenger-carrying commercial aircraft
• Breach of law committed by the life assured at the time of accident
• Death / Disability in case of war (whether declared or not) or civil commotion
• Accident as a result of hazardous sports / hobbies (e.g. Bungee jumping)
  

6. Typically under what circumstances would an accidental rider claim be rejected by the company?

A few circumstances when accidental claims are rejected are given below:

• Temporary disability such as fractures
• Partial disability such as loss of finger
• Policy in lapsed condition on date of accident
• Policyholder had not opted for accident rider at all

Please note: Exhaustive detail of the rider benefits, conditions and exclusions is given in the policy document.

Comp/doc/Dec/2008/891

LAPSED POLICY

1. What does the term “lapse” or “lapsation” mean for life insurance business and what are the implications for the policyholder?

There are three types of policies - single, regular and limited premium paying policy.

Single premium policies - The premium is paid only once i.e. at the time of policy commencement for the entire term. Therefore, question of lapsation does not arise for single premium policies.

Regular/ Limited premium policies - The premium is payable by the policyholder at regular intervals during the premium paying term. The premium payment term and frequency is shown on the policy certificate. The company allows a grace period of 30 days for half yearly and yearly frequency and 15 days for monthly frequency. A regular/ limited premium policy lapses if the premium is not paid on the due date and during the grace period. If a policy is not in the premium holiday period it is necessary to pay premium on the due date or during the grace period

Depending on the terms and conditions mentioned in the policy document, life cover and other benefits payable under the policy cease or are reduced once the policy is lapsed/ paid up, however, the policyholder will continue to have the benefit of investment in the respective unit funds.

2. Would the life cover and other benefits be available during the grace period where the premium is not paid on the due date?

The policy would enjoy the life cover and other benefits during the grace period. However, if the premiums are not paid within the grace period the policy would lapse/ become paid up.

3. Are the premiums returned to the beneficiary in the unfortunate event of life assured’s death while the policy remains lapsed?

There is no provision to pay any amount in a lapsed policy unless specifically mentioned in the policy contract.

Comp/doc/Dec/2008/891

UTMOST GOOD FAITH

1. What is Utmost Good Faith?

An insurance contract is known as a contract of 'Uberrima Fides' or a contract based on 'Utmost Good Faith'. It means all parties to an insurance contract must disclose all material facts. Any fact which would influence the judgment of an insurer in fixing the premium or determining whether to accept the risk is a material fact.

2. What is “Non disclosure” or “Mis statement”?

When a fact influencing the underwriting decision is not disclosed in the proposal, it is termed as “non disclosure”. Similarly, withholding information or providing incorrect information while answering questions in the proposal form is “mis-statement” e.g. when an applicant who is suffering from kidney failure answers in the negative to a question on kidney ailment, it is non disclosure of material fact. When an applicant states that he is salaried but does not mention that his job is highly hazardous, it is a mis statement.

3. How does “Non disclosure” or “Mis statement” affect insurance?

Insurance is sharing of risk by creating a pool of funds out of the premium paid by the policyholders. This means that when a claim arises, the payout takes place from the common fund which belongs to all the policyholders. Therefore, an Insurer has a duty to protect the interests of the policyholders at large and cannot pay fraudulent claims out of the common fund thereby penalizing the other policyholders. Based on this principle, claim can be repudiated by the insurer on account of non disclosure or mis statement. In legal terms, if one party commits breach of contract by not maintaining the declaration (in the proposal form) of having replied truly and correctly, the other party i.e. the insurer is not liable to honor the claim.

4. What is the recourse available to the claimant when his/ her claim is repudiated?

ICICI Prudential Life Insurance Company follows a practice of sending a detailed written communication to the claimant explaining the reasons for repudiation of a claim. The company also sends a copy of the proposal form with an aim to ensure complete transparency of the decision taken. The claimant is also informed about the Internal Grievance Redressal Committee of the company as well as about the Office of Insurance Ombudsman with the appropriate address. The claimant is advised to write to the Grievance Redressal Committee within 30 days. After careful evaluation of the matter, the committee gives a decision on the representation made by the claimant within 30 days of receipt which is conveyed to the claimant. If the response is not satisfactory to the claimant, he/ she can approach the Office of Insurance Ombudsman for re-examination of the matter. The Consumer Forums can also be approached by the claimant for redressal of grievances.

5. When does the company conduct verification of a claim?

ICICI Prudential Life Insurance Company believes in paying only genuine claims to protect the interest of the policyholders. In order to ascertain genuineness of a claim and weed out fraudulent ones, the company at times needs to conduct verification of claims.

Comp/doc/Dec/2008/891

INSURANCE REGULATORY DEVELOPMENT AUTHORITY

1. What is IRDA?

Insurance Regulatory Development Authority(IRDA) has been set up to protect the interests of the policyholders, to regulate, promote and ensure orderly growth of the insurance industry and for matters connected therewith or incidental thereto (This definition has been taken from IRDA website)

2. What are IRDA guidelines pertaining to claim processing?

As per IRDA,

• Insurance company is required to settle a claim within 30 days of receipt of all requirements
• If the claim warrants further verification, the company should complete its procedures within 6 months from receipt of written intimation of the claim
• If the company settles the claim beyond 6 months period, then interest is payable by the company on the claim amount
• The interest is payable only where the claimant has submitted all the requirements. Further, rate and period of interest are decided as per IRDA guidelines

3. What is Insurance Ombudsman?

Insurance Ombudsman has been established through a Government notification for quick disposal of the grievances of insured customers. There are 12 offices in the country and approaching an Insurance Ombudsman is cost free. The Ombudsman is empowered to give award (decision) for insurance contracts up to Rs.20 lakhs. Once the grievance is lodged, the office of Ombudsman arranges a hearing which is attended by the claimant and the representatives of the Insurer. Usually the award of the Ombudsman is expected within three months of the hearing. The addresses of the Ombudsman offices are available on our website and also on IRDA website (www.irda.gov.in).

Comp/doc/Dec/2008/891