Case Study 47 - Tata AIG Life Insurance told to pay Rs 2.5 lakh

The district consumer disputes redressal forum ordered an insurance company to pay a complainant Rs 2.5 lakh for her treatment of a cardiac ailment.
The insurance company was rejecting her claim saying that the illness for which she was treated was not covered under the policy.
The woman had purchased a 'health first' insurance policy from Tata AIG Life Insurance Company Limited, valid for a period of 13 years, from January 9, 2004, to January 9, 2017.

As per the policy, the insurance company had to pay the complainant's hospital and medicine expenses, in case of a serious ailment. The policy amount was Rs 5 lakh. In July 2005, the woman felt pain in cardiac region and consulted several doctors for treatment, even in Mumbai. In October 2005, the woman was given a permanent pace maker by doctors. She was admitted in a hospital in Mumbai for treatment. The treatment cost her Rs 4.5 lakh and she filed a mediclaim with the insurance company.

The insurance company paid her Rs 1,500 only, for being admitted in the hospital for three days, at Rs 500 per day, as was defined in the policy. The company denied paying other expenses saying her illness was not a 'critical illness'.

After being taken for a ride by the insurance company, the aggrieved woman filed her complaint with the consumer forum.

The company confessed that it had rejected her claim because the illness for which she was treated was not covered under the said policy. The illness necessitating a permanent pace maker was also not specified in the policy taken by the woman.

The critical illness cover promised the woman 'a lump sum payment of up to Rs 5 lakh' in case she was diagnosed with a critical illness.

The policy further said that it will ensure that woman has access to the most technologically advanced treatment, and can pay for medicine related costs and other recuperation costs.