Complaint filed on: 20-04-2010 <br /> Disposed on: 22-09-2010<br /> <br /> BEFORE THE BANGALORE IV ADDITIONAL DISTRICT <br /> CONSUMER DISPUTES REDRESSAL FORUM,<br /> BANGALORE URBAN DISTRICT, NO.8, SAHAKARA BHAVAN, CUNNINGHAM ROAD, BANGALORE – 560 052 <br /> <br /> C.C.No.886/2010<br /> DATED THIS THE 22nd SEPTEMBER 2010<br /> <br /> PRESENT<br /> <br /> SRI.D.KRISHNAPPA., PRESIDENT<br /> SRI.GANGANARASAIAH., MEMBER<br /> SMT. ANITA SHIVAKUMAR. K, MEMBER<br /> <br /> Complainant: - <br /> Sri.M.Suresha, Major, <br /> Son of late C.Muniyappa, <br /> R/at No.2, Anugondanahalli, <br /> M.M.Kadugodi, Whitefield, <br /> Bangalore-560 037<br /> <br /> <br /> V/s<br /> <br /> Opposite parties: - <br /> 1. M/s. TATA AIG Life Insurance<br /> Company Ltd, Branch <br /> Operation No.102, <br /> Consulate-1, No.1, Richmond Road, Bangalore560 025<br /> <br /> Also at:<br /> <br /> 2. M/s. TATA AIG Life Insurance <br /> Company Limited, <br /> Registered & Corporate office:<br /> 6th floor, Peninsula towers, <br /> Peninsula corporate park, <br /> Ganpatrao Kadam Marg,<br /> Lower parel (W), Mumbai-13 <br /> <br /> O R D E R<br /> <br /> SRI. D.KRISHNAPPA., PRESIDENT., <br /> <br /> The brief facts of the complaint filed by the complainant against the opposite parties [hereinafter called as OPs for short) are that the complainant’s wife had taken a health benefits police from the Ops which came to be issued on 2-11-2009 with benefits like surgical benefit Rs.25,000/-, post hospitalization benefit Rs.250/-, daily hospital benefit Rs.500/-, critical illness benefit Rs.2,50,000/- and term benefit Rs.2,000/. That during November 2009 the insured had developed high fever was taken to a local hospital on 8-11-2009 was admitted to Manipal hospital on 9-11-2009 was in-patient till 19-11-2009 and she expired on the same day at 18.30 hours because of H1N1 disease. That the complainant incurred medical expenditure and he made claim of Rs.2,46,468/- under the terms of the policy, he is entitled to claim critical illness benefit to the tune of Rs.2,50,000/- as he is the beneficiary of his deceased wife. That he submitted his claim to Ops, but the Ops calculating the claim under term life at Rs.2000/- and thereby deducting unpaid premium of Rs.2,240/- have contravened term of the policy has denied the benefit under the critical illness and under the term life has settled to the tune of Rs.2000/-. Therefore the complainant calling this act of the Ops as deficient has prayed for a direction to the Ops to pay benefits of Rs.2,46,468/- with interest.<br /> <br /> 2. OPs have appeared through their advocate and filed their common version, contending that the complaint is not maintainable, admitting to had issue the policy called “HEALTH FIRST”. It is stated that they are not aware of death of the insured due to H1N1pneumonia. The Ops relying upon the definition of the critical illness as found from the conditions of the policy have stated out of 12 listed critical illness H1N1 disease do not fall and that condition covering benefit of critical illness is not covered, have further stated that the insured died within 16 days after issue of the policy. Therefore the complainant is not entitled for the benefit under the critical illness heading and have stated under the policy, the complainant is entitled for term life benefit i.e. Rs.2000/- and considering deduction of premium after death, as per the term of the policy the insured beneficiary is entitled to Rs.2000/- only and unpaid premium for the rest eight months accounted to a total of Rs.2240/- was deducted from the benefit payable to the complainant and thereby denying the liability, have prayed for dismissal of the complaint. <br /> <br /> 3. In the course of enquiry into the complaint, the complainant and the authorized signatory of the Ops have filed their affidavit evidence reiterating what they have stated in their respective complaint and version. The complainant alongwith the complaint has produced a copy of the policy, copy of terms and conditions of the policy, copy of death summary of the hospital with a copy of death certificate and copy of a legal notice he got issued to the Ops. The Ops have also produced a copy of the policy and copy of the terms and conditions of the policy. The counsel for the complainant has filed written arguments. We have heard the counsel for the Ops and perused the records.<br /> <br /> 4. On the above contentions following points for determination arise.<br /> 1. Whether the complainant proves that the Ops have caused deficiency in their service in not paying the critical illness benefit under the policy?<br /> 2. To what reliefs, the complainant is entitled to?<br /> <br /> 5. Our findings are as under:<br /> Point no.1: In the Negative <br /> Point no.2: See the final Order<br /> <br /> REASONS<br /> <br /> 6. Answer on Point No.1: Before we proceed to the allegation of the complainant, defence of the Ops and arguments of the counsel for both the parties, it is relevant to refer to the nature of the policy that the deceased had availed and issued by the Ops. The policy issued to the deceased is called “HEALTH FIRST POLICY” which was taken to avail schedule benefit under the policy. Schedule benefit and premiums paid are mentioned in the policy itself. The policy is called TATA AIG life health first, which is the health insurance benefit policy under which the insured would be entitled for surgical benefit of Rs.25,000/-, Post hospitalization benefit of Rs.250/-, daily hospital benefit of Rs.500/-, Critical illness benefit of Rs.2,50,000/-. These are the benefits for which the insured was entitled and the complainant who is the nominee would become entitle. Admittedly the insured who was suffering from high fever was admitted to hospital on 11-9-2009 and died on 19-11-2009 due to H1N1pneumonia. After death of the insured, the complainant has came up with this complaint claiming critical illness benefit under the policy claming Rs.2,50,000/-. Therefore it is necessary to mention here that the complainant has not claimed any other benefits like surgical benefit, post hospitalization benefit etc. but claiming critical illness benefit to extent of Rs.2,50,000/-. Therefore whether the complainant is entitle for such benefit or not under the terms of the policy is to be considered. <br /> <br /> 7. The Ops in their version and also affidavit evidence denying the entitlement of the complainant under the heading critical illness benefit have contended that conditions of the policy provide 12 diseases as a critical illness but H1N1 do not fall within that 12 critical illness that are defined under the conditions of the policy. The Ops also further contended that the conditions necessary for extending from the definition of benefit of critical illness are not there in the present case and therefore stated that the complainant is not entitled for the benefit. As detailed by the Ops in their version 12 illness are described as critical illness which are cancer, stroke, Heart Attack, Coronary Bypass surgery, Chronic renal failure, major organ transplant, aorta surgery, benign brain tumor, heart valve surgery, paralysis, Parkinson’s disease and total blindness. The Ops argued that H1N1 do not fall within these 12 diseases called critical illness and therefore have contended that the wife of the complainant since was not suffering with any such critical illness, the complainant is not entitled for the critical illness benefit. The Ops have also further contended by referring to the conditions required to avail the benefit of critical illness stated the signs or symptoms of which first must have commenced after more than 180 days following the issue date or commencement date of the policy which ever least or the first diagnoses. Therefore it is argued that even though that H1N1 disease is not a critical illness it was not diagnosed after 180 days after issue of policy but was diagnosed within 16 days from the date of issue of the policy and therefore even that count also, the complainant is not entitled for the crucial illness benefit. <br /> <br /> 8. Even under the terms and conditions of the policy under meaning of critical illness benefit the insured after she was diagnosed of the critical illness must have survived for a period of atleast 30 days or first performance of any of the surgery for critical illness. In the case on hand, the insured did not survive for at least 30 days to avail the benefit under critical illness benefit. It may be argued that, when the terms and conditions of the policy were framed H1N1 was not at all identified in the medical field and that disease is of later invented one, therefore not listed as critical illness within the definition of critical illness. But the condition of attack the critical illness must have been diagnosed after 180 days after issue of the policy to confer the benefit under that heading. But in the case on hand within 16 days after issue of policy the insured was diagnosed with H1N1. Therefore the complainant considering from any angle in our view is not entitled for the benefits. The conditions further speak that if the policy is taken for benefits of daily hospitalization benefit, post hospitalization benefit, surgical benefit, critical illness benefit then no death benefit is payable under the policy to the beneficiary. Therefore in the case on hand, the Ops considering the nature of the policy the deceased availed and also considering that the complainant has not proved that his claim fall within critical illness benefit scheme have refused honour his claim, but settled the claim of the complainant under the head “life time limit” which in our view does not amount to deficiency in the service of the Ops. The complainant therefore in our view has failed to prove his entitlement for the benefit under definition critical illness benefit and the complaint is therefore liable to be dismissed by answering point no.1 in the negative and pass the following order.<br /> ORDER<br /> <br /> Complaint is dismissed. Both parties to bear their own cost.<br /> <br /> Dictated to the Stenographer, Got it transcribed and corrected, Pronounced on the Open Forum on this 22nd September 2010.<br /> <br /> <br /> <br /> Member Member President<br />