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Award Dated 31.1.2005Husband of the Complainant was a Policy Holder of LIC. He died due to PulmonaryTuberculosis. Claim lodged by the Complainant was repudiated on the ground of incorrectstatement and withholdment of correct information committed by DLA. Documents andsubmissions perused. It is observed from the certificate dated 20-9-02 that the DLA wasunder treatment of Cottage Hospital for Pulmonary Tuberculosis from June 1999 toNovember 1999. Further observed that the DLA’s answer to specific question relating topast history was in negative. Suppression of facts and breach of Utmost Good Faithestablished. Repudiation upheld.Ahmedabad Ombudsman CentreCase No. LIC / 2 / 159Smt. Pravinaben B. ShahVs.Life Insurance Corporation of IndiaAward Dated 8.2.2005Complainant, wife of DLA. The Claim Lodged by her was repudiated under Clause-6 ofPolicy Conditions. Issues examined are whether the repudiation was as per Policyconditions as well as the suicide of the LA could be proved by evidences. Documentsperused. It is observed that the cause of death has been indicated in the final PoliceReport as suicide by drowning in Sea. The motivation behind the suicide is indicated asdamage of shop by earthquake and subsequent recession in business. Repudiation underClause - 6 upheld. Policy No. 813862314.Ahmedabad Ombudsman CentreCase No. LIC / 2 / 147Smt. Sajanba N. KheradiaVs.Life Insurance Corporation of IndiaAward Dated 8.2.2005On the death of LA, the Complainant lodged Claim for Policy benefits which was repudiatedon the ground of non-disclosure of material facts with regard to Liver Cancer suffered bythe DLA one month earlier to the Proposal dated 30.1.2002. Documents and submissionsperused. It is observed that in MAC issued from H.J. Doshi Hospital the duration of LiverCancer has been mentioned as 4 months prior to the date of death of DLA on 18.8.2002.The COHT issued by N.P. Cancer Hospital has been mentioned only the date of admissionin the Hospital on 10.8.2002 and the COHT was not filled-up completely. Therefore, boththe certificates are not supportive to corroborate the Respondent’s contention in therepudiation letter. Another document examined was a letter from one Dr. Vipul Desai. It isobserved that the contents in the said letter is only probabilistic, but not assertive andhence opined that such probabilistic statement cannot be a valid document for repudiationof a death Claim. Further observed that the investigation done by a Senior Officer of theRespondent Company also could not come out with any adverse conclusion with regard togenuineness of the Claim. Further, the DAL had underwent full medical Tests and acomplete medical report from a Senior Doctor in the panel of Respondent was submittedand the Proposal was accepted on OR Already Decided case in the matter of LIC Vs G.M.Channabasamma 1(1991) ACC 411 (DB) also referred. Respondent to pay Rs. 5,00,000/-along with 8% simple interest. Policy No. 813023235.Ahmedabad Ombudsman CentreCase No. LIC / 2 / 158Smt. Kokilaben R. BarotVs.
Life Insurance Corporation of IndiaAward Dated 22.2.2005After the death of LA, his wife lodged Claim With the Respondent for Policy benefits. Onthe ground of non-disclosure of sick leave taken by the DLA with respect to certaindiseases alleged to have been suffering prior to the Proposal for insurance, Respondentdenied liability. They Claimed to have indisputable proof to establish suppression of factand mis-statement based on COHTs issued by Dr. J.D. Shah, Dr. C. C. Kalaria and Dr. Y.R. Joshi. Documents and submissions perused. It is observed from these COHTs that theDoctors in all these Certificates only advised Rest putting question marks against thediseases mentioned and there was nothing to prove that any treatment was given nor anyTests for diagnostic purpose were conducted. Hence, all these certificates served to be assupportive documents for availing medical leave. Further observed that the in-houseinvestigation conducted by the Respondent also couldnot bring out any evidence ofsuppression of fact or mis-statement which ultimately recommended to treat the Claim asgenuine. Decided cases in the matter of LIC Vs Sanjeev Mahendralal Shah [I (1998) CPJ45 (NC)], LIC Vs. Paramjit Kaur Gill [III (1997) CPJ 35] and Nirmala soni Vs. LIC & Others(2004 CCJ 217) were also referred. Respondent to pay Rs. 314600/- alongwith 8% simpleinterest to the Complainant. Policy No. 851198951.Bhubaneswar Ombudsman CentreCase No. I.O.O.O. / BBSR / 24 - 202Smt. Sarojbala BeheraVs.Life Insurance Corporation of IndiaAward Dated 01.11.2004Happened that Late Surath Chandra Behera of Vill. Damodarpur P. O. Kantapada, Dt.Cuttack had obtained a Nav Prabhat Plan without Profit under Table & Term 137-15 bearingPolicy No. 583445223 from Cuttack Dist. Branch of LIC of India, Cuttack Division for a SumAssured of Rs. 1,50,000/- with Qly. mode of payment nominating the Complainant asbeneficiary in the event of his death. As ill luck would have it, he died on 12.1.2002. LIC ofIndia repudiated the claim on the ground of suppression of material fact.Complained that LIC repudiated the claim on flimsy ground i.e. availing of Sick leavebefore taking the Policy. Actually the deceased was not suffering from any serious disease.As he no other leave to his credit he availed Sick leave.Countered by LIC that the deceased Life Assured had not only availed of medical leavebefore taking the policy but also had taken reimbursement of medical bills by submittingprescriptions of the doctor & medical bills etc.Observed that the Life Assured was working as PA (BCR), Head Post Office, Rayagada.The Sr. Superintendent of Post Offices, Koraput Division in his letter No. E-15-13/00-01dtd. 27.10.04 has submitted Essential Certificates, Prescription etc. produced by thedeceased life assured for availing of medical bills reimbursement, from which it appearsthat he was being treated by Dr. N. Dash, Medicine Specialist, D. H. H. Rayagada from27.8.99 to 16.12.99 for hypertension & I. H. D. He mooted the proposal on 18.3.2000declaring that he had no pre-existing disease and was in good state of health though in facthewas suffering from heart disease and died of heart disease about a year there after.Evidently he obtained policy by misrepresentation.Held that LIC was justified in repudiating the Claim. The complaint was dismissed withoutany relief.Bhubaneswar Ombudsman CentreCase No. I.O.O. / BBSR / 21 - 141Smt. Tofani Behera
Page 3 and 4: of treatment for urinary tract infe
Page 5 and 6: Mr. Ramesh D. MakwanaVs.Life Insura
Page 7 and 8: Case No. 21 - 001 - 0249Mr. K. D. D
Page 9: Complainant’s husband took a Poli
Page 13 and 14: produced the father of the assured
Page 15 and 16: Unfortunately, the Assured died on
Page 17 and 18: questionnaire in the proposal form.
Page 19 and 20: suffering from the said ailment pri
Page 21 and 22: Case No. LIC / 344 / Ludhiana / Lud
Page 23 and 24: Findings : The complainant asserted
Page 25 and 26: the Doctor and undergo treatment. T
Page 27 and 28: Smt. Lalitha @ LalliVs.Life Insuran
Page 29 and 30: insurance but did not disclose the
Page 31 and 32: suicide. Since the same was exclusi
Page 33 and 34: 3 years as per policy conditions. T
Page 35 and 36: suppression of material information
Page 37 and 38: Smt. C. AnnapooraniVs.Life Insuranc
Page 39 and 40: was placed on the decisions of the
Page 41 and 42: Case No. IO (CHN) / 21.08.2405 / 20
Page 43 and 44: Life Insurance Corporation of India
Page 45 and 46: Shri K. Perumal, the nominee under
Page 47 and 48: The repudiation decision was upheld
Page 49 and 50: The complaint under all 3 policies
Page 51 and 52: Case No. IO (CHN) / 21.08.2509 / 20
Page 53 and 54: Smt. K. Tamilselvi took a LIC polic
Page 55 and 56: In short, LIC has no valid ground a
Page 57 and 58: Smt. Lakshi DeviVs.Life Insurance C
Page 59 and 60: Findings : It appears that on the s
Page 61 and 62:
proposal for assurance, the opposit
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Life Assured was guilty of any brea
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time. This ground of incorrect info
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Fact of The Case : One Shri Y. C. M
Page 69 and 70:
Fact of The Case : Shri G. Prabhaka
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disease with chronic bronchitis and
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Decision : I heard the contentions
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ii) It was alleged by the insurer t
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ii) The insurer repudiated the clai
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The life assured was admitted there
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Award Dated 08.10.2004Facts of The
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I heard the contentions of both and
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admitted with diabetic pulmonary ed
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22/7069); 09.08.2002 (S. No. 5/7897
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date of birth as 05.07.1946 at the
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established beyond all doubt that t
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x) Therefore, for the reasons as af
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Decision : I have carefully perused
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it was a very early claim, the insu
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Hyderabad Ombudsman CentreCase No.
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Finding the life assured to be guil
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6. In the result the complaint is c
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ecords, the insured underwent werth
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ix) Therefore, I have to hold, for
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suppression of material facts relat
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particulars like father’s name an
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solemn obligation to make full disc
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ix) Having regard to the facts and
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y 13 years at the timeof taking the
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from this hospital in the form of d
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iv) In support of their repudiation
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cause of death was reported to be c
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assured was sleeping in his cot, he
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months and 11 days and hence the in
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having a bearing upon the acceptanc
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above. The insured died on 27.04.20
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Shri Cherukuri RajeshwariVs.Life In
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(iii) In support of their repudiati
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AFFECTIVE DISORDER AND ASPIRATION P
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Severe LV dysfunction, Cognestive C
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Award Dated 12.2.2005Facts of the C
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of this act after expiry of two yea
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initiated by them. In any considere
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that the life assured, while submit
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value of the policy, as ex-gratia b
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indisputable proof to show that eve
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Case No. L / 21 - 001 - 0267 - 2004
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insured to make a full disclosure o
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vii) According to the same dictiona
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justice and also give fair opportun
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Decision : I have carefully perused
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insurer in the claim form no. 5152
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Tetralogy. This admission and the t
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insured did not declare any income
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case on hand, the insurance policy
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not fulfill all the three ingredien
Page 175 and 176:
Page 177 and 178:
Page 179 and 180:
not been heard of for seven years,
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The duration of the claim for risk
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eviewing the decision of the respon
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Even if the Life Assured were alive
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The complainant under Rule No. 12(1
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Award Dated 22.2.2005Facts / Submis
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Award Dated 07.10.2004Shri Chandray
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view of this, the claimant approach
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was conveyed to the claimant by the
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Employer’s Certificate and leavel
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Vs.Life Insurance Corporation of In
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normally develops in childhood. Thu
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Certificate dated 3.3.03 issued by
Page 205 and 206:
were not disclosed. Under the circu
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the deceased life assured withheld
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his health at the time of effecting
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history of Appendectomy 15 years ba
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Mumbai Ombudsman CentreCase No. LI
Page 215 and 216:
Shri Raju Shankar Makadwale took tw
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life assured withheld material info
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Respiratory Arrest” and the secon
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epudiated by Nagpur DO of LIC stati
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Therefore, there was suppression of
Page 225 and 226:
eceived on 12.08.04 by the company,
Page 227 and 228:
Life Insurance Corporation of India
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