Employers Liability Insurance Claim Process

Scope of Cover and Documents required for Claims

The policy covers statutory liability of an employer for the death of or bodily injuries or occupational diseases sustained by the workmen arising out of and in course of employment.

Who can be insured?

Any employer whether as a Principal or contractor engaging "workmen" as defined in WC Act to cover his liability to them under statute and at common law? Employer can cover Employees who do not qualify as "Workmen" under separate table

Scope

  • To pay all sums which the insured is legally liable to pay the employees in respect of personal injury by accident or diseases `arising out of and in the course of the employment.
  • Insured`s liability arising either under common law or the laws set out in the schedule Workmen`s Compensation Act 1923.
  • Costs or expenses incurred by the insured with the consent of the company, to defend any claims are paid in addition.

Exclusions:

  • Any injury by accident or disease directly attributable to war and nuclear risk
  • Insured`s liability to employees of contactors to the insured
  • Any liability of the insured which attaches by virtue of an agreement. Any compensation for diseases mentioned in Part `C` of Workmen`s Compensation Act-1923.

Documents required for claims:

  • Intimation to Insurance Company.
  • Submission of claim form together with the summons received from Court.
  • FIR to be lodged with Police authorities for Death and Bodily injuries.
  • Copy of Accident Register mentioning the time, date and the occurrence of the event.
  • First Aid details provided together with the Medical reports for payments made by the Employer.
  • For Cases of death claims Inquest report and Postmortem Certificate are required.
  • Copy of attendance register to show that the worker was employed with the Insured on that date.
  • Copy of Movement Register to show that the employee had gone out on official work or not.
  • Copy of tour reports or tour plans of employees who are stationed outside the headquarters.
  • Pay Bill copy to show the wages received by the employee.
  • Details of any interim compensation paid to the employee.
  • Details of Hygiene maintained at the premises to ward off occupational diseases.
  • Previous details of any claims paid for occupational diseases.
  • Copy of Medical Pristine visits and his observations.
  • Copy of visits by Inspector of Labor. Inspector of Factories, Sanitary Inspectors from local body.

In the event of Claims being repudiated by the Insurance Company the following options are available as a recourse:

  • Make a representation to the Insurance Company/TPA.
  • If no reply is received within 15 days on making such representation make a representation to the Grievance Cell of the Insurance Company.
  • If No Reply is received or if the reply is not satisfactory then make a representation to the Insurance Ombudsman who has Quasi Judicial powers to hear the case and make adjudication.
  • If still not satisfied the next option is to go to court.