Basic Cover and Benefit Payments 基本保障與利益支付
The personal accident section pays the amount assigned to the insured event in the schedule of benefits. Typical wording requires accidental, violent, external and visible means during the policy period to be the sole and direct cause of bodily injury, with the injury sustained within one year of the accident. Exact wording differs between insurers.
Territorial restrictions also matter. Some policies cover accidents only outside the place of origin. If Hong Kong is the insured person's place of origin, an accident on the journey home from the airport after returning to Hong Kong may fall outside this section.
Under the arrangement described in this section, where one accident produces several insured bodily injury events, only the event carrying the highest benefit is paid. Once a benefit becomes payable to an insured person under this section, no benefit is payable to that person under it for another accident.
Some policies provide double benefits for qualifying accidents while travelling in a private car, a coach arranged by a travel agency, or purely as a fare-paying passenger in a common carrier. A common carrier may be defined as a public conveyance licensed to carry passengers. Some policies also extend double benefits to qualifying bodily injury suffered as an innocent victim of robbery or attempted robbery.
Insured Events and Disablement Definitions 受保事件與傷殘定義
Insured events may include death; loss of both eyes, two limbs, or one eye and one limb; loss of one eye or one limb; loss of hearing in both ears; loss of speech; permanent total disablement; and third degree burns. Third degree burns destroy the full thickness of the skin. Some policies also cover second degree burns, which damage both the epidermis and the underlying dermis.
Loss of limb may mean physical separation at or above the wrist or ankle, or permanent loss of use of the limb. Actual amputation is therefore not essential. Loss of an eye may mean total, irrecoverable and irremediable loss of sight in that eye, rather than physical loss of the eyeball.
Loss of hearing may require permanent and irrecoverable deafness in both ears that surgery or other treatment cannot remedy. Loss of speech may require total and irrecoverable loss of the ability to speak that surgery or other treatment cannot remedy.
One typical definition of permanent total disablement requires complete inability to perform any gainful occupation for at least 12 continuous months, with no reasonable hope of improvement at that point. Inability to return to the previous job alone is insufficient. For someone without a gainful occupation when the accident occurs, such as a housewife, a policy may instead assess inability to perform normal daily duties.
Exclusions, Sports and Age Restrictions 不保事項、運動及年齡限制
Hazardous activities may be excluded, including mountaineering, winter sports and aviation other than as a fare-paying passenger. Sports provisions vary between policies. Some exclude only professional sports undertaken for income or remuneration, so identical restrictions should not be assumed across all policies.
Some plans cover selected activities within stated restrictions, such as scuba diving to no more than 40 metres below the surface. Winter sports and underwater activities may attract reduced benefits or limits of liability. An insurer may also agree, on request and for an additional premium, to extend cover to selected sports.
Other common exclusions include suicide, deliberately self-inflicted injury, alcohol or drug abuse, and injury resulting from disease. A serious or fatal illness during a trip does not become a personal accident claim merely because its outcome is severe: the accident and bodily injury requirements must still be met.
Benefits for an insured person outside a specified age range are normally reduced to a stated amount or proportion. A policy might use ages 18–75 as that range, but this is an example of policy wording, rather than a compulsory age boundary for every travel policy.
Claims Evidence and Applying Policy Terms 索償證據與條款的運用
Whether an event is accidental depends on the policy definition and the facts. The cases illustrate that a foreseeable attack after deliberately joining a fight, or a foreseeable consequence of surgery for disease, may fall outside the relevant accident definition. An unfortunate outcome alone does not establish an accident.
The claimant needs evidence supporting the accident and its causal link to the injury. Absence of a visible bruise or wound does not necessarily disprove an accident; evidence from an employer or witness may help. Medical records can distinguish accidental injury from an existing condition or disease. Previous claims can be material facts at application, and deliberate concealment may lead to rejection of a claim.
Exclusions require attention to causation and wording. An exclusion for death caused directly or indirectly by motorcycling was applied to a motorcycle passenger. Conversely, an unrelated road accident in a war zone did not activate a war exclusion. In another case, the policy's purpose supported interpreting 'violation of law' as intentional criminal acts rather than mere traffic infringements; that interpretation cannot automatically be applied to every policy.
Notification periods run from the event specified in the wording. A requirement to notify within 30 days after an accident does not start on recovery. Acceptance of an earlier late claim does not require the insurer to accept later ones. Whether late notification supports rejection depends on the wording and matters such as prejudice to the insurer's investigation; rejection is not automatic in every case.
Practice
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