Claims Report

The different types of riders offered by the company are as follows:

• Personal accident benefit rider (PAB) provides benefit in case of accidental disability


• Accidental death rider benefit (ADB) provides benefit in case of accidental death


• Critical illness rider benefit provides benefit in case of occurrence of any of the conditions/surgeries stated in the contract


• Waiver of premium rider benefit (WOP) provides benefit in the form of premium waiver in case of accidental disability/death of the payer

For details on rider benefits, please refer the policy document.

The exclusions under the rider benefits are stated below:

• In case the dreaded disease/surgery occurs within waiting period (90 to 180 days) of the policy issuance, subject to the contract terms and conditions*


• If the condition/surgery is not covered under the policy terms and conditions*


• Accidental injury, which occurs due to self-inflicted injury


• In case, the life assured commits suicide within one year of the policy issuance


• In case, the life assured is involved in any unlawful activity resulting in injury


• In cases where the injury occurred is not as per the policy terms and conditions*

*For details on exclusions, please refer to the policy pack.

Few instances when an Accidental rider claim gets rejected are:

• Temporary disability such as fractures


• Conditions where it is partial disability e.g., toe amputation


• A lapsed policy as on the date of accident


• In case of any material non-disclosure at the time of proposal signing

Critical illness/Dreaded disease:

• A lapsed policy on the date of event


• In case of any material non - disclosure at the time of proposal signing


• If the condition/ surgery is not covered under the policy terms and conditions


• If the criteria for the illness/surgery is not fulfilled as per the policy terms and conditions

*For other comprehensive details, please refer to the policy terms and conditions.

The claimant/nominee information for different policy structures is as follows:

• GTL in lieu of EDLI Policy: Nominee mentioned as per the Provident Fund Nomination Form


• GTL – Axis Max Life Super Life (Employer-Employee) Policy: Policyholder / company


• GTL – Gratuity Policy: Policyholder trust


• Lender Borrower Scheme: Outstanding loan amount in favour of the Master Policyholder & balance claim amount in favour of the Nominee registered at the time of coverage commencement


• Non Lender Borrower Scheme: Nominee registered at the time of coverage commencement

***The nomination may vary depending upon the policy terms and conditions

Such circumstances are 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 and our liability as an insurer will be discharged. 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.

“Actively at work” clause means on the date the coverage commences :

• i) The employee is performing his regular duties as assigned to the employee on a full time basis;


• ii) The employee is not on leave due to any illness or injury or maternity leave.

If the member is absent on the date the coverage commences, due to any illness or injury or maternity leave the coverage shall not commence until the date of his/her joining to duties and performing in the usual way all of the regular duties of his/her job on a full time basis and submit health declaration.

An addition/deletion request is used to update member records under a group policy. Members who have joined the organisation should be included as additions, while members who have resigned, retired, or been terminated should be included as deletions.
A death claim should be reported separately and must not be treated as a deletion request. If a covered member has passed away, the death should be notified through the prescribed claims process and should not be included in any declaration confirming that no deaths have occurred during the reporting period.

For employer-employee schemes, the nominee registered in PF or policy records is eligible. In lender-borrower cases, the outstanding loan is paid to the master policyholder, and the remaining benefit goes to the nominee. These rules define how group claims are processed under the insurance claim process.