COMPREHENSIVE/PERSONAL ACCIDENT BENEFIT –
FREQUENTLY ASKED QUESTIONS
1.
What is the definition of “Temporary Total Disability”?
Temporary Total Disability means disability arising from accidental bodily injury, which entirely
prevents the Person Insured(s) from attending to his business, profession or occupation from the
date of accident.
2.
What is the definition of “Temporary Partial Disability”?
Temporary partial Disability means disability arising from accidental bodily injury, which prevents
the Person Insured(s) from attending to one or more duties pertaining to his business, profession
or occupation from the date of cessation of Temporary Total Disability.
3.
What are the procedures to make a claim?
Please ensure that the cause of loss is due to an accident.
a. Written notice to be given to the company./ You have to complete the Accident claim form.
b. Notice to be given within 14 days for:- CPABO, CPAB, E-BIG and HOME SERVICE and
Notice to be given within 28 days for:- for ECPAB, ECPABM, RCPAB, RCPABM, MPA and
CAR from date of accident.
c. Documentations as evidence required by the company are furnished at the cost of the Policy
Owner.
d. Documentations submitted to the company for the purposes of a claim shall not be returned
e. Claim shall not be payable after attainment of age:i. Attainment age for:- HS is 60 years.
ii. Attainment age for:- CPABO, CPAB, E-BIG, ECPAB, ECPABM, RCPAB, RCPABM and
MPA is 65 years.
iii. Attainment age for:- Child accident rider is 25 years.
4.
How do I complete the Claim Form?
a. There are two parts of the Claim Form:Part A : Claimants Statement, Appendix A (under employment)
Part B : Attending Physician’s Statement
b. All questions in the Claim Form are to be answered in full. Tick (π) or dashes ( - ) are not
acceptable.
c.
Original receipts for medical reimbursement must be verified and confirmed by the Branch
Officer.
Note: Disbursement will only be made on original receipts.
d. For claims less than RM220.00, the injury must be stated on the Medical Certificates and
countersigned by either the doctor/CAM/UM/BE/BO.
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CPAB/FAQ - Version 1 / 30 Nov ’07
Claims Below RM 220.00
a. Part A of the claim form must be completed.
b. Appendix A must be completed by the employer.
c. Confirmation on the nature and extent of injury from the Branch Manager, B.E, B.O, CAM /
UM / Hospital Authorities/Medical Officer.
Claims Exceeding RM 220.00
a. Part A of the claim form must be completed.
b. Part B of the claim form must be completed by the medical officer.
c. Appendix A must be completed by the Employer (under employment).
5.
What documents do I need to submit?
Medical Certificate, Appendix A, original receipt, photocopy itemized bill, SOCSO form and police
report it any.
a. Basic Documents:i. The claim form must be completed in full and signed by the claimant and witness.
ii. Original receipts and bills for AMRB and Medical and Surgical Expense Reimbursement.
iii. Medical Leave Certificate and Light Duty Certificate must be certified if photocopy is
submitted. (Original is required if self-employed).
iv. SOCSO Borang 13 and Borang 21 or SOCSO payment voucher – In the event of
accident at work place including going and coming back from workplace.
v. Employer’s confirmation Appendix A of the claim form must be strictly completed by the
employer.
b. Medical and Surgical Reimbursement Documents:ii. Original Official Receipts
iii. Original/Copy – Itemized Bill
c.
Additional Documents:The Company reserves the right to verify with the medical officer/employer or request for
further supporting documents/evidence when necessary.
i.
ii.
iii
iv.
v.
vi
vii.
viii.
ix.
x.
xi.
SOCSO Borang 13
SOCSO Borang 10
SOCSO Payment Voucher
Pay Slip
Premium Pass Book (Home Service Policies)
Photographs (proof of loss of limb and etc)
Medical Report
Consent Form
Attending Physician’s Statement (Part B) (Claims above RM220)
Discharge Note (with nature of injury stated) or Discharge Summary
Letter from Employer (confirmation on nature of light duty performed/medical record
history and etc.)
xii. IC Extract Form
xiii. X-ray Report (for fracture cases)
xiv. Newspaper cutting (if any)
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CPAB/FAQ - Version 1 / 30 Nov ’07
Child Accident Reimbursement (CAR)
a. Basic Documents:i. Claim Form
ii. Original Official Receipts
iii. Original/Copy – Itemized Bill
b. Additional Documents:i. Attending Physician’s Statement (Part B)
ii. Discharge Note (with nature of injury stated) or Discharge Summary
iii. Medical Certificate (when necessary)
Note: 1.
Any alterations on the documents issued by the hospital/clinic must be countersigned
by the hospital/clinic authority with official seal affixed/stamped.
2. Medical Certificate (MC) should be certified as true copy only upon sighting the original
Medical Certificate by the Employer/Branch Manager/BE/BO/CAM/UM/Hospital
Authorities/Medical Officer.
6.
Do you need original documents?
Yes. Original documents are required for purposes of submitting a claim especially for selfemployed cases and for medical reimbursement cases.
For employee under employment, certified true copy from employer is required
7.
How long does it take to process the claim?
It depends, if the documents are all in order it takes one day.
8.
Why do I have to submit SOCSO form?
This is to support the evidence that the medical leave submitted is due to accident.
9.
Why Appendix A is necessary to be completed for employee under employment?
This is to confirm that you are working at the same place of employment and your period of
disability is consistent to your medical leave entitlement.
10.
Some of my MCs have been missing. Can I still get my claim?
Yes. Kindly write to us and we will deduct and pay the balance according to the policy terms and
conditions.
11.
Doctor has already confirmed that I should be given TTD period and why justification is
still needed?
If the medical leave is of longer duration for the given injury, justification and clarification is further
needed (eg. injury abrasion of hand) to establish that there are other contributing elements
leading to the longer duration of disability. E.g diabetic or infection.
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CPAB/FAQ - Version 1 / 30 Nov ’07
12.
How long does it take for a claim to be processed for cases which have been referred to
adjuster or awaiting for medical report?
It depends on case per case basis and the response of the relevant authority.
13.
Can I authorize my agent to collect my cheque?
Yes, you may do so, provided the agent is UM and above. In other instances, a letter of
authorization is required.
14.
What are the exclusions under this benefit?
The benefits shall not apply if it should result, either directly or indirectly, from;
a. self-inflicted injuries or suicide while sane or insane.
b. bodily infirmity or mental or functional disorder or illness or disease of any kind, or any
infection, other than infections occurring simultaneously with and in consequence of an
accidental cut or wound.
c. taking of poison or the inhaling of gas, whether voluntary or otherwise.
d. any injury sustained:i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
15.
while on duty in any navy, army, air force, police or fire brigade.
from war, invasion, act of foreign enemy, hostilities (whether war be declared or not), civil
war, rebellion, revolution, insurrection, military or usurped power, strike, riot or civil
commotion.
from engaging in aerial flights including parachuting and sky diving other than as a fare
paying passenger or crew member on a regular public air service.
as a result of the Person Insured(s) committing, attempting or provoking an assault or a
felony or from any violation of the law by the Person Insured(s).
while under the influence of alcohol, drugs or narcotic.
from engaging in racing of any kind other than on foot.
from engaging in any underwater activity.
wilful or negligent exposure to unnecessary risks or perils.
Does the Accident Benefit cover ailment?
No. Ailment is not covered under Accident Benefit policy because this benefit only covers injuries
caused by accident.
16.
Does the coverage include outside Malaysia?
Yes. The coverage is worldwide.
17.
I have already made a claim from other insurance companies, can I still make the claim
again with your company?
Yes. You may make a claim with us on the medical leave but not on the medical reimbursement.
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