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Shri M. Solai VadivelVs.Life Insurance Corporation of IndiaAward Dated 23.12.2004Smt. S. Muthulakshmi (Late) took a LIC policy for a sum assured of Rs. 25,000/- whichcommenced on 15.2.2001. She appointed her father on behalf of the nominee, her minordaughter. She died on 5.3.2003 due to Rheumatoid Arthritis, Pleural Effusion andrespiratory failure. The claim for policy monies was repudiated. On appeal Zonal ClaimsReview Committee paid Rs. 5000/- representing 20% of the sum assured as Ex-gratia. Theclaimant preferred a complaint before this Forum for full sum assured along with Bonusunder the policy.Parties to the dispute were heard and the records perused. The complainant denied herdaughter ever having taken any medical treatment for Rheumatoid Arthritis beforeproposing for insurance and that the recording contained in the hospital records was wrongsince he did not a company her daughter to the hospitals at all. But the certificates of the 2Government hospitals recorded the history of Rheumatoid Arthritis as 3 and 5 years andthat the life assured was on steroids for the past 5 years as reported by the attendants ofthe patient. The information contained in the two Govt. hospital’s records could not brushedaside and positive inference of pre-proposal ailment could definitely be drawn. There wastherefore material suppression. At the same time, since the sum assured was low and the Insurerfailing to prove fraudulent suppression satisfying Section 45 of the Insurance Act with irrefutableevidence, to ensure equity and justice, LIC was directed to pay 50% of the basic sumassured to the complainant as Ex-gratia, subject to recovery of Rs. 5000/- paid already.The complaint was partly allowed and LIC was orderded to pay an Ex-gratia of Rs. 12,500/-.Chennai Ombudsman CentreCase No. IO (CHN) / 21.04.2328 / 2004 - 05Smt. B. SakkinaVs.Life Insurance Corporation of IndiaAward Dated 23.12.2004K. Badhusha (Late) took a policy of insurance on his life with LIC for a sum assured of Rs.5 lakhs which commenced on 28.1.2003. He nominated his wife Smt. B. Sakkinathereunder. He died on 25.09.2003 due to Carcinoma Nasopharynx. The claim wasrepudiated for suppression of material information relating to health of the life assured. Therepudiation decision was upheld by the Zonal Claims Review Committee on appeal andhence the present complaint.A personal hearing was held. The complainant contended that special reports were takenand the life assured was medically certified fit. She accepted that her husband hadoccasional nose bleeding. But she was not aware of Cancer since the first consultation withhospital took place only 3 months after taking the policy. The documents were perused.The hospital records evidenced than the life assured had complaints of swelling on both theside of his neck, difficulty in hearing and history of Epistaxis, stretching back to the preproposalperiod and was referred there for further management of the disease. Evidentaly,the life assured had suffered from serious complications of health and the symptoms of thedisease Cancer had already manifested prior to taking the policy and the life assured hadtaken treatment elsewhere before being referred to the hospital concerned for furthermanagement. Surely tests like ECG and BST underwent by the life assured could not throwany light on Cancer and there was substance in the argument of the Insurer that, had thelife assured disclosed the pre-proposal ailments, LIC would have conducted full blood testsand opportunity to make proper assessment of the risk was denied to them. Civilcomplaints could be decided on the basis of preponderance of probabilities and reliance
was placed on the decisions of the Hon’nle Supreme Court of India in M. Krishnan vs VijaySingh & Anr and Hon’ble High Court of Kerala in Manni vs Paru. Since Section 45 of theinsurance Act was not applicable in full and the Insurer could prove material suppressionon the basis of medical evidence, the repudiation decision LIC of was upheld. However theInsurer was directed to take stringent action against the Agent and the Medical Examinerfor their dereliction of duties and devise appropriate underwriting safeguards.The complaint was dismissed.Chennai Ombudsman CentreCase No. IO (CHN) / 21.07.2296 / 2004 - 05Smt. B. MythiliVs.Life Insurance Corporation of IndiaAward Dated 2.12.2004S.Balan (Late) proposed for a policy for Rs. 1 Lakh on his life with LIC vide his proposaldated 28.3.2002. The proposal was received by LIC on 30.3.2002. The decision to acceptrisk was taken on 3.4.2002. The life assured died on 29.3.2002 before the decision toundertake the risk was made. The insurer repudiated the claim on ground that the lifeassured suppressed material information pertaining to his health. The repudiation decisionwas upheld by the Zonal Claims Review Committee. The complainant, thereafterrepresented to this forum for reconsideration.Personal hearing was held and records perused. The hospital records produced by theInsurer did evidence that the life assured had undergone treatment for Peptic Ulcer,substance abuse and had also undergone piles surgery six months before proposing forinsurance but did not disclose the same in his proposal. It was also a case of unconcludedcoutract since proposal paper was received by the Insurer only after death of the lifeassured and therefore no concluded contract came into existence. However the Insureradopted a liberal approach and considered the claim. Since there was a materialsuppression, the decision to repudiate claim was upheld. Reliance was placed on thedecision of the Hon’ble Supreme Court of India in LIC vs Raja Vasireddy Komalavalli thatcontract was not complete until the decision to accept risk was communicated.The complaint was dismissed.Chennai Ombudsman CentreCase No. IO (CHN) / 21.08.2313 / 2004 - 05Smt. R. GunasundariVs.Life Insurance Corporation of IndiaAward Dated 8.12.2004K. Rajendran (Late) took a policy of insurance on his life for Rs.25,000/- with LIC which commenced on 10.11.1999. He nominated his wife Smt. R.Gunasundari under the policy. The life assured died on 5.10.2001 due to MyocardialInfarction and Asthma. The insurer repudiated the claim on ground of suppression ofmaterial information pertaining to health. The repudiation decision was upheld by the ZonalClaims Review Committee. The complainant preferred a complaint to this Fourm.The complainant was not present for the personal hearing but submitted that the Agent hadobtained signature on blank proposal form and that Section 45 of the Insurance Act wasattracted and hence LIC was not entitled to repudiation of claim. The extensive hospitalrecords produced by the Insurer revealed that the life assured was a known Asthmaticpatient and was taking treatment therefor. He underwent hospitalisation and treatment anddiagnosed as hypertensive with Ischaemic Heart Disease and Antero Septal Mayocardial
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 and 10: Complainant’s husband took a Poli
Page 11 and 12: Life Insurance Corporation of India
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: Smt. C. AnnapooraniVs.Life Insuranc
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
Page 63 and 64: Life Assured was guilty of any brea
Page 65 and 66: time. This ground of incorrect info
Page 67 and 68: Fact of The Case : One Shri Y. C. M
Page 69 and 70: Fact of The Case : Shri G. Prabhaka
Page 71 and 72: disease with chronic bronchitis and
Page 73 and 74: Decision : I heard the contentions
Page 75 and 76: ii) It was alleged by the insurer t
Page 77 and 78: ii) The insurer repudiated the clai
Page 79 and 80: The life assured was admitted there
Page 81 and 82: Award Dated 08.10.2004Facts of The
Page 83 and 84: I heard the contentions of both and
Page 85 and 86: admitted with diabetic pulmonary ed
Page 87 and 88: 22/7069); 09.08.2002 (S. No. 5/7897
Page 89 and 90:
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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Decision : I heard the contentions
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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
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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
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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
Page 217 and 218:
life assured withheld material info
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Respiratory Arrest” and the secon
Page 221 and 222:
epudiated by Nagpur DO of LIC stati
Page 223 and 224:
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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