What types of injuries or illnesses are typically excluded from coverage under workmen compensation insurance?
Workmen compensation insurance doesn't cover an injury or illness caused by the influence of drugs or alcohol. Also, self-inflicted injuries or the occurrence of an accident due to the wilful disobedience of the rules by the employee are excluded.
How does the nature of employment or work-related tasks impact the exclusions under workers compensation insurance?
Jobs involving high-risk activities such as construction, firefighting and mining may have different exclusions compared to office-based roles as in the former, chances of injuries are higher.
Are there any pre-existing health conditions that may be excluded from coverage under WC insurance?
Pre-existing health conditions not directly caused by work activities can be excluded from coverage. One needs to consult with the respective insurer to learn more about it.
In what situations might a workmen compensation insurance claim be denied based on policy exclusions?
Claims for non-fatal injuries and those that don't cause partial disablement for more than 3 days can be denied. Also, claims for self-inflicted injuries or that caused under the influence of drugs or alcohol are excluded.
What are the basic coverage provided under Employee (Workmen's) Compensation policy?
The policy provides coverage for accidental death, permanent total disability, permanent partial disability and temporary total disability
What addon covers are provided in Employee's (Workmen's) Compensation policy?
- Occupational Disease
- Compressed Air Disease
- Contractor /Sub Contractor Coverage
- PAN India Location Coverage
- Medical Expenses (Per Employee Limit)
- Cashless for Medical Expenses
What is Permanent Total Disablement?
"Permanent total disablement" means such disablement of a permanent nature as incapacitates an employee
for all work which he was capable of performing at the time of the accident resulting in such disablement.
List of disablements is specified in the Employee's compensation Act.
What is Permanent Partial Disablement?
Permanent partial disablement" means, where the disablement is of a permanent nature, such disablement as
reduces the earning capacity of an employee in every employment which he was capable of undertaking at
the time of the accident resulting in the disablement. List of disablements is specified in the Employee's compensation Act.
What is Temporary Disablement?
Temporary disablement" means a condition resulting from an employment injury which requires medical
treatment and renders an employee, as a result of such injury, temporarily incapable of doing the work which
he was doing prior to or at the time of the injury.
What is Employee's compensation insurance?
The Employee's Compensation Insurance provides for payment of compensation to Employer on behalf of its employees in case of accidental injury to at workplace arising out of and in the course of employment and resulting in death or disablement
- Employee's compensation claims are for accidents within work premises and during working hours
- It also covers direct travel of employees from office to home and vice-versa
- At the time of injury, workman must have been engaged in the business of the employer and must not be doing something for his personal benefit
- Employer and employee relationship is an important prerequisite for issuance of Employee's compensation (EC) policy
What legal liabilities are covered in Employee's compensation policy?
- Employee's Compensation Act, 1923 [As Amended through Employee Compensation (Amendment) Act, 2017], and subsequent amendments of the said Act prior to the date of issue of the policy.
- Fatal Accidents as per Fatal Accident Act, 1855
- Common Laws
How is Employee's Compensation policy different from ESIC (Employee State Insurance)?
- Construction site workers are excluded from ESIC coverage as per ESI Act but can be covered in WC policy
- Employees with wages above 21000 not covered in ESIC but there is no limit of wages under WC/ EC Act
- Seasonal Factories (Includes factories engaged Less than 7 Months) are not covered in ESIC, but can be covered in a Employee's compensation policy
- Organization with up to 10 workers (20 in case of Maharashtra and Chandigarh) does not require to have ESIC registration however there is no restriction as to no. of workers in WC /EC policy
- Lower and flexible rates as compared to fixed ESIC Rates
What is occupational disease cover?
Occupational Diseases covers those diseases that are specified under Schedule III of Employee or Employee's Compensation Act. It covers those disease which arise due to nature of occupation Ex. disease caused by use of toxic compounds
What is Compressed Air Disease cover?
Compressed air disease is one of the occupational illnesses covered under Employee's compensation policy. It is a
sickness attributed to the working environments where air pressure may be higher or lower than the normal
surface air pressure. Ex. Underground or underwater works.
What does Medical Extension add on cover?
Medical extension covers reasonable medical surgical and hospital expenses incurred by the Insured in connection with any case of injury of employee, if hospitalisation is for more than 24 hours
What is covered under Contractor /Sub Contractor Coverage?
Contractor / Sub-contractor and their employees can be covered under this coverage.
What is PAN India Location Coverage?
If the insured has more than 1 risk locations (operating branches or factories) across the country, PAN India
coverage enables employer to take a single insurance policy to cover its employees in all the branches.
What is the purpose of workmen compensation (WC) insurance?
The primary purpose of workmen compensation insurance is to protect both employers and employees. For employers, it helps cover the costs associated with workplace injuries or illnesses for their employees, along with shielding them from the expenses of potential lawsuits. For employees, it gives them the necessary financial cushion and support during injuries suffered at the workplace.
Who is responsible for obtaining and maintaining workers compensation insurance?
Employers are responsible for obtaining and maintaining workers compensation insurance. As an employer, you must ensure that the coverage meets the requirements set by law and remains active and up-to-date.
What types of injuries or illnesses are typically covered by WC insurance?
WC insurance typically covers a range of injuries and illnesses that can happen in the workplace as a result of work-related activities, including physical injuries, occupational diseases, and even mental health conditions.
How is the premium for workmen compensation insurance determined?
The premium of workmen compensation insurance is calculated depending on several factors, including the nature of work, the number of employees and their salaries, claims history, industry operation, and location, among others.
What steps should an employee take if they are injured at work?
When an employee is injured at work, he / she should immediately seek medication attention and report the injury to the employer as soon as possible. One should also provide complete details about how the injury happened and its nature to the employer so that claims can be filed from the workers compensation insurance policy.
What basic information the Insurer needs to provide quotation?
- Nature of work / Occupancy
- No. of Employees
- Monthly wages
- Policy duration
- Risk Location Address
- Claim Experience of last 3 years with amount and count of claims
How Sum Insured is calculated in a Employee's compensation policy?
- Sum Insured is the total earnings of the employees in the organisation.
- The Sum Insured is calculated on the basis of monthly wages of employees.
- Wages includes basic salary, allowance, perquisites or any benefits provided to the employees
(Other than reimbursable expenses made by employees)
What is the process for filing a claim under workmen compensation insurance?
The first thing is to inform the employer about the injury or illness, post which the employer will ask to furnish details of the accident. After this, the employer will notify the insurance company about the accident, fill out the claim form, and provide the necessary documents related to the accident. Post this, the insurance company will verify the claim's authenticity, based on which the claim can be approved or denied.
What documentation is required when submitting workers compensation insurance claim?
The documents required are:
- Authorized Disability certificate from Govt hospital-Civil Surgeon
- Cancel Cheque with Printed Name of the claimant
- Death certificate, in case of death
- Duly filled in WCM Questionnaire
- FIR/MLC/Police final report
- Hospital Discharge Summary, Treatment papers, Investigation reports
- Any other document asked by the insurer
How long does it generally take for a WC insurance claim to be processed?
On most occasions, the TAT for claim settlement is 14 days. If the claim is sent to the surveyor, it would take another 15 days over and above the 14-day TAT.
Are there specific criteria that determine the approval or denial of workers compensation insurance claim?
After investigation, if the insurance company is satisfied with the claim's authenticity and finds it aligns with the policy's terms and conditions, it will approve the claim. On the other hand, if it finds inconsistencies, it may reject the claim.
What support services are available to employees during the claims process under workers compensation insurance?
Employees generally receive guidance and support on claims assistance, related paperwork, etc. They can also get support for medical care from their employers.
What information is required for Claim intimation?
- Policy Number
- Insured Name
- Injured Name
- Date of Accident (Loss)
- Nature of Claim - TTD (temporary total disablement) / PPD (permanent partial disablement) etc
- Brief description of accident
What is the amount of compensation payable under Employee's Compensation policy?
Employee's Compensation is a statutory liability as prescribed under Employee Compensation Act which provides for amount of compensation as below:
| Nature of Claim |
Amount of Claim |
| Accidental Death |
(50% * Wages * Age Factor) OR INR 1,20,000 Whichever is higher |
| Permanent Total Disability |
Permanent Total Disability (60% * Wages * Age Factor) OR INR 1,20,000 Whichever is higher |
| Permanent Partial disability |
Based on % disability / Loss of earning capacity prescribed
by medical practitioner * Wages * Age Factor |
| Temporary total disability |
Temporary total disability 25% * wages * No of days of absence/disability / 15 |
*As prescribed by central govt. notification, maximum amount of wages to be considered for compensation is INR 15000 per month