DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Usha Jain w/o Late Sh. Shil Chand Jain, R/o H.No. 681, Harmilap Nagar, Panchkula.

              ---Complainant

Vs.

1.   TATA AIG Life Insurance Co. Limited, Regd. Office, 5^th & 6^th Floor, Peninsula Towers, Peninsula Corporate Park, Ganpatrao Kadam Marg, Lower Parel, Mumbai. 

2.   TATA AIG Life Insurance Co. Limited, Branch Office: SCO No. 107 & 108, 2^nd Floor, Sector 43-B, Chandigarh – 160047.

---- Opposite Parties

BEFORE:   MRS.MADHU MUTNEJA            PRESIDING MEMBER

SH. JASWINDER SINGH SIDHU    MEMBER

Argued By:    Sh. Sandeep Bhardwaj, Counsel for Complainant.

           Sh. Nitin Thatai, Counsel for Opposite Parties.

PER MADHU MUTNEJA, PRESIDING MEMBER

1.          The husband of the Complainant had taken an insurance policy from the Opposite Parties effective from 24.12.2009 by paying an initial premium of Rs.18,000/-. The payment was to be made annually. The husband of the Complainant was informed at the time of receiving the premium that the Complainant will get not only the treatment expense but also sum assured in the policy which is Rs.3.85 lacs. This was the amount paid on the death of the insured. The policy was related to the market investment. The husband of the Complainant signed the proposal form (Annexure C-1) and thereafter, the policy was issued. The Complainant has alleged that though her husband had paid 03 continuous premiums, the Opposite Parties did not supply copy of account statement annually to the Complainant to make him aware about the status of his investment. The husband of the Complainant after serious illness passed away on 06.07.2012 (death certificate Annexure C-2). Opposite Parties were duly informed about the hospitalization as well as the death of the patient. The Complainant also completed all formalities required for the claim (receipt Annexure C-3). However, the Complainant was surprised to receive an amount of Rs.41,832.52/- vide Cheque No. 730387 dated 29.08.2012, besides another amount of Rs.4950/-. The amount of Rs.4950/- was for surgical benefit. However, the Opposite Parties when questioned about the amounts could not give any proper reply. The Complainant has thus filed the present complaint claiming the insured amount of Rs.3.85 lacs besides compensation and costs of litigation.     

2.          Notice of the complaint was sent to Opposite Parties seeking their version of the case.

3.          Opposite Parties in their joint reply have maintained that the deceased Sh. Shil Chand Jain had approached the Opposite Parties for purchase of TATA AIG Life Invest Assure Health which is an investment Unit Linked Plan. The deceased life assured was fully aware of the contents of the application/ proposal forms and the risk involved in the plan. It was only an investment policy against which daily hospitalization benefit plus surgical benefits were also available. Since the Opposite Parties have already paid the fund value of Rs.41,832.52/- and Rs.4950/- on account of surgical benefits in accordance with terms of the policy, nothing more remains due to the Complainant.

          The Opposite Parties have explained that as per the policy the following benefits were provided:- (a) Maturity benefits (b) Maturity bonus (c) Death benefit. Since the life assured died before the maturity period of the policy therefore his nominee was entitled to the death benefit. As per policy, if the covered member dies while the policy is in force and before the maturity date, Opposite Parties will pay to the nominee the total fund value of the policy at the applicable unit price as specified in the Section “cut-off time for determining the appropriate valuation date” under the fund provisions following their receipt and approval of written notice and due proof of death. Opposite Parties have also contended that the life assured was well aware of the policy and all necessary literature had been provided with regard to the product, nature and its significance of the policy (proposal form Ex.R-2). Opposite Parties have also referred to the judgment of the Hon’ble State Consumer Disputes Redressal Commission, U.T. Chandigarh in Appeal No. 198 of 2012 titled as Shashi Miglani V/s TATA AIG Life Insurance Co. Limited. It was maintained that the Complainant was well aware of the terms and conditions of the policy and had not applied for cancellation within the free look period and hence her request for cancellation had righty been rejected. Thus the prayer of the Complainant for payment of Rs.3.85 lacs along with compensation is not acceptable. Opposite Parties have further maintained that this amount was not payable on the death of the life assured. The policy was an investment policy and only fund value was payable. Besides health product in the coverage available to the life assured was daily hospitalization plus surgical benefits. Opposite Parties have therefore prayed for dismissal of the complaint.    

4.          Parties were permitted to place their respective evidence on record, in support of their contentions.

5.          We have heard the learned counsel for the parties and have perused the record. 

6.          The grievance of the Complainant is that though her husband was assured for a medical benefit as well as life insurance of Rs.3.85 lacs, the Opposite Parties have paid Rs.41,832.52/- and Rs.4950/- on account of surgical benefits only. The Opposite Parties on the other hand have maintained that whatever was payable to the Complainant as per the terms of the policy, has been released to her and nothing has been retained. In this regard, reference needs to be made on the policy placed on record by the Opposite Parties at Ex.R-3.

7.          As per definitions, “sum assured” is the amount specified on the Policy Information Page which is equal to 730 multiplied by the initial Daily Hospital Benefit payable per day (provided that the Covered Member’s Confinement is not in an ICU) which shall be our maximum liability for any and all claims made by each Covered Member during the term of the Policy.

          “Maturity Benefit” means if any of the Covered Members are alive on the Maturity Date and the Policy is in force, we will pay to you the Total Fund Value of this Policy at the applicable Unit Price as specified in the section “Cut-Off time for determining the appropriate valuation date.

          “Death Benefit” (a) If the policy covers only one Covered Members at the time of death: If the covered Member dies while the policy is in force and before the maturity date, We will pay to the Nomine the Total Fund Value of this policy at the applicable Unit Price as specified in the section “cut off time for determining the appropriate valuation date” under fund provisions following our receipt and approval of written notice and due proof of death.

          “Cut-Off time for determining the appropriate valuation date” (c) In case of a death claim, valid application shall mean written notice of claim and filing of due proof of death in accordance with the Claims Procedures of the Policy (as described hereinbefore).

          “Daily Hospital Benefit” means while this Policy is in force, if the Covered Member is confined in a Hospital for Medically Necessary treatment of a Covered Injury or Covered Illness, We will pay the lump sum Applicable Daily Hospital Benefit as defined below for each day of stay in Hospital arising out of an accident or sickness (any one during one Hospitalization) provided there has been an overnight stay in the Hospital. No pre-existing sickness would be covered under this product.

8.          The Complainant has been paid the fund value in terms of the death benefit which is Rs.41,832.52/- as per the claim made. Complete details of fund value of the amount invested by the Complainant has been placed on record by the Opposite Parties at Ex.R-4 to show the amount due to the Complainant. The due amount has been paid.

9.          The Complainant has also been paid Rs.4950/- towards daily hospitalization and surgical benefit. As per Annexure C-1, a sum of Rs.500/- was to be paid to the Complainant towards Daily Hospital Benefit. However, the Complainant has not placed on record the details of the number of days that the life assured has remained hospitalized to prove that more amount was due to her than the amount paid by the Opposite Parties.

10.        The claim of the Complainant with regard to Rs.3.85 lacs along with interest cannot be paid, as the policy has not reached its maturity. The policy was an investment policy and the daily hospitalization plus surgical benefits were additionally available. As per the terms of the policy, the coverage available to the life assured during the pendency of the policy was only the fund value besides daily hospitalization plus surgical benefits, which has already been paid by the Opposite Party.

11.        Hence we do not find any merit in the complaint as the allegations made by the Complainant are not substantiated by cogent evidence. We accordingly, dismiss the complaint with no order as to costs.

12.        The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

18^th June, 2013                                 Sd/-

   (MADHU MUTNEJA)

PRESIDING MEMBER

Sd/-

(JASWINDER SINGH SIDHU)

MEMBER

“Dutt”