Complete a claim form and together with all supporting documentation submit directly to Accident & Miscellaneous Acceptances:

Transcription

1 TEACHERS SCHEME ASSISTERE - CLAIMS PROCEDURE GUIDELINE GROUP PERSONAL ACCIDENT Our Persnal Accident plicy prvides a benefit t emplyees, wh suffer accidental bdily injury. Accidental Bdily Injury culd be the result f any f the fllwing: Mtr vehicle / bus accident Sprts Injuries Injuries n Duty Injuries at hme Murder and Assault Snake r dg bites etc HOW TO SUBMIT A CLAIM? Cmplete a claim frm and tgether with all supprting dcumentatin submit directly t Accident & Miscellaneus Acceptances: Telephne Fax tewaterd@sha.c.za and attachments@sha.c.za Pstal address P.O.Bx 55347, Nrthlands, 2116 All claims must be ntified as sn as pssible, but within 180 days frm the date f the injury. Failure t d s will result in the claim being declined fr late ntificatin. EXCLUSIONS There is a list f Exclusins that yu must be aware f, which are as fllws: The Insurers shall nt be liable t pay any claim under this Plicy in respect f any Insured Persn 1. while engaging in flying as pilt r member f the crew. This exceptin des nt apply t Insured Persns engaging in ballning, hang-gliding, paragliding and parachuting, prvided that such activities are slely fr scial and/r pleasure purpses and nt f a cmpetitive nature r fr reward 2. caused by the Insured Persn's suicide r intentinal self-injury 3. caused slely by an existing physical defect r ther infirmity f the Insured Persn 4. as a result f the influence f drugs r narctics upn the Insured Persn unless administered by a member f the medical prfessin (ther than himself) r unless prescribed by and taken in accrdance with the instructins f a member f the medical prfessin (ther than himself) 5. fr Bdily Injury t the Insured Persn arising frm any mtr vehicle accident ccurring whilst the Insured Persn is driving r perating any mtrised r mechanically perated vehicle whilst being under the influence f alchl. Fr the purpses f this exceptin the term under the influence f alchl means having a Bld Alchl level Cncentratin (BAC) greater than the statutry limit at the time f the accident, r the level applicable accrding t prevailing legislatin where the accident ccurs, whichever is the lesser 6. caused by the Insured Persn's participatin in any rit r civil cmmtin 7. arising frm war, invasin, act f freign enemy, hstilities (whether war be declared r nt), civil war, rebellin, revlutin, insurrectin, military r usurped pwer Claims prcedure June

2 8. as a result f the Insured Persn's deliberate expsure t exceptinal danger (except in an attempt t save human life) r the Insured Persn's wn criminal act 9. while participating in sprt as a prfessinal player. 10. directly r indirectly caused by r cntributed t by r arising frm inising radiatins r cntaminatin by radiactivity frm any nuclear fuel r frm any nuclear waste frm the cmbustin f nuclear fuel r frm any nuclear weapns material. Fr the purpse f this exceptin nly, cmbustin shall include any self-sustaining prcess f nuclear fissin. Exceptin (1) is waived t include cver fr an Insured Persn wh engages in single engine aircraft expsure fr Leisure purpse and nn reward up t a maximum f R per incident SUICIDE CLAIMS Yu will nte that suicide is excluded n the Plicy. Hwever, if yu have reasn t believe that the emplyee cmmitted suicide, yu must still fllw the prcedure fr the death claim. Fllwing a suspected suicide attempt, the plice d a full investigatin t determine the events that lead t the death and there are times where suspected suicides are fund t be cnstructed murder cases. This investigatin des hwever take a lng time and we wuld prefer t advise the Insurer f the pssible claim within the 180 days, just t prevent the claim being declined fr late ntificatin 2 years later when we find ut the actual cause f the death. CLAIM DOCUMENTS NEEDED Once the claim has been submitted t the Insurers they will advise exactly what dcumentatin is required t fully assess the claim. The dcumentatin required fr each claim varies n the circumstances f the claim. A useful guide t the claim requirements is nted belw, where full dcumentatin is received it allws the administratr t finalize yur claim quicker: Mtr Vehicle Accident Murder, Hijack r Assault DEATH CLAIMS If there are newspaper clipping abut the accident/incident in any f these instances, these are very useful Fully cmpleted claim frm Cnfirmatin f earnings Pst Mrtem Reprt Traffic Cllisin Reprt Bld Alchl Results (if driving the vehicle) Pedestrians killed whilst crssing a rad Fully cmpleted claim frm Cnfirmatin f earnings Pst Mrtem Reprt Traffic Cllisin Reprt Fully cmpleted claim frm Cnfirmatin f earnings Pst Mrtem Reprt Plice Reprt f the incident If there is a newspaper clipping abut the accident, this is very useful. PERMANENT DISABILITY CLAIMS This is a unique benefit and the claims requirements differ fr every single claim that is submitted, as the Insurers need t get specialist medical reprts frm the attending medical practitiner Mtr Vehicle Accident Fully cmpleted claim frm Cnfirmatin f earnings Fully cmpleted Medical Reprt, attached t claim frm Traffic Cllisin Reprt Pedestrians injured whilst crssing a rad Fully cmpleted claim frm Cnfirmatin f earnings Fully cmpleted Medical Reprt, attached t claim frm Plice Reprt f the incident Injuries resulting frm an Assault r Hijacking Fully cmpleted claim frm Cnfirmatin f earnings Fully cmpleted Medical Reprt, attached t claim frm Plice Reprt f the incident Newspaper reprts (if any) Sprts Injuries r Injuries at hme Fully cmpleted claim frm Cnfirmatin f earnings - Fully cmpleted Medical Reprt, attached t claim frm Claims prcedure June

3 HOW TO OBTAIN THE REQUIRED INFORMATION It is imprtant t nte that the quicker yu start asking fr the infrmatin, the easier it will be t btain the dcumentatin. Mst death claims are delayed because nbdy knws where t btain the infrmatin and this can be avided by being practive, as fllws: As sn as yu have been ntified by the cmpany r by the family that an emplyee has died frm accidental bdily injury, yu shuld get in cntact with the family immediately and tell them that yu need certain dcumentatin t prcess a death claim. Plice Case Number Death Certificate Pst Mrtem Reprt All unnatural deaths are reprted t the plice and they are all investigated by the plice. The family must advise which plice statin the case was reprted t, the case number and the name f the investigating fficer immediately after they reprt the case t the plice. The family has t reprt the death t the plice and t the Hme Affairs ffices. Tell them that they have t prvide yu with a certified cpy f the death certificate. This will speed up the claims prcess. If smene dies frm Unnatural Causes, a pst mrtem reprt is always dne, as they need t determine the cause f the death. This reprt is usually nly available 4-6 weeks after the date f the death and the family shuld advise the plice that they require a cpy f the reprt as sn as it becmes available. It is imprtant that yu remind the family t fllw up with the plice fr these dcuments, as it will speed up the claims prcess Traffic Cllisin Reprt All mtr vehicle accidents must be reprted t the plice within 24 hurs f the ccurrence f a mtr vehicle accident. This reprt is usually cmpleted n the day f the accident and shuld be available t the family within 5 days f the accident. The family shuld again advise the plice that they require this reprt fr an insurance claim and fllw up with the plice until they get the reprt. Plice Reprt Newspaper Clippings/Reprts In the event f a death resulting frm an assault, murder r hijacking situatin, the plice will issue a reprt detailing the infrmatin that they have regarding the incident. This reprt generally takes a bit lnger t btain, as there are usually a number f witnesses that the plice need t talk t befre they can be sure f the exact circumstances surrunding the incident. In mst cases there will nt be any newspaper reprts f the incident. Hwever, there are times where there are reprts in the lcal newspapers abut the incident. Ask the family f they have seen any reprts and if they have a cpy f the reprt. This is very useful in the assessment f the claim and will certainly speed up the claims prcess. General Remember that the family has the easiest access t the infrmatin that is required and if they are practive, the claim will be assessed far quicker Claims prcedure June

4 Once the emplyee has advised yu f his claim, yu have t give him a cpy f the Medical Reprt attached t the claim frm and tell him t ensure that his dctr cmpletes the frm.. It is imprtant t nte that these claims can take up t 24 mnths t finalise, as the Insurer always has t make prvisin fr sufficient healing time and als time fr pssible deteriratin f the emplyee s cnditin HIV/AIDS ACCIDENTAL EXPOSURE If an Insured Persn is accidentally expsed t HIV/AIDS the fllwing assistance will be prvided and managed n a cnfidential basis: 24-hur emergency assistance helpline, which will arrange fr the necessary help the Insured Persn may require where Trauma and/r HIV infectin may be the result f an Assault Instant access t medical prfessinals diagnstic and access t hspital care t manage the cnsequences Specific Cnditins Cver is prvided within the brders f Suth Africa nly All incidents must be reprted t within 48 hurs ACCIDENT EXPERT The Insured will have access t assistance with all claims management and handling in respect f the fllwing by cntacting r Guardrisk@radcver.c.za Cmpensatin fr Occupatinal Injuries & Disease Act (COID) Assistance Rad Accident Fund Act (RAF) Assistance Legal Assistance needed fllwing a rad accident ACCIDENTAL DEATH COURTESY CAR HIRE In the event f the accidental death f an immediate family member f an Insured Persn this plicy is extended t include a car hire benefit as defined belw and subject t the Specific Definitins and Specific Exceptins. Fr assistance cntact assistere@guardrisk.c.za direct Claims prcedure June

5 Specific Definitins in respect f this extensin nly Car Hire Benefit shall mean: an AVIS Grup B vehicle r a passenger carrier nt exceeding 14 seats Unlimited kilmetres Cllisin Damage Waiver except R3,000 excess fr each and every claim payable by the driver t ur prvider Theft Lss Waiver except R3,000 excess fr each and every claim payable by the driver t ur prvider prvided that; the car hire shall be limited t a maximum f 7 (seven) days; Immediate family shall mean: Spuse which shall include a cmmn law partner the Insured Persn s dependant children wh are nt in full-time emplyment and wh are between the ages f 3 mnths and 19 years (r under the age f 25 years prvided they are in full-time educatin), unmarried, nt pregnant, withut children and primarily dependent n the Insured Persn fr maintenance and supprt Specific Exceptins applicable t this extensin nly: N benefit shall be payable under this extensin in respect f; Refundable depsits; Fuel Depsit; Additinal Driver r Driver Excess; One way fees within Suth Africa r any Crss Brder Fee; Delivery & Cllectin; Baby Seat; Fines/Claims Handling; Claims prcedure June