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Award Dated 29.10.2004Mr. Vanmali Patel who had been holding LIC Policy died on 20.7.1993. The maturity date ofthe Policy was 15.12.03. On 18.7.03 Respondent sent maturity intimation letter to DLA andanother letter dated 22.10.03 for compliance. On receipt of these letters, Complainant Smt.Ramaben Patel informed the Respondent on 28.01.04 about the LA’s death in 1993 andclaimed for the proceeds of the Policy which was turned down by the Respondent.Respondent submitted that the LA died on 20.7.1993 was never intimated to them and as aresult, the Policy continued in its Paid-up status. The death was intimated only in Januarry2004 and hence, the case became time barred and except this infirmity, they have noproblem to settle the Claim. Complainant submitted that she or her family was not aware ofthe existence of the Policy till they received the letters from LIC. Documents andsumbmissions perused. It is observed that except afflux of time there is no infirmity in thiscase. Nothing found to disbelieve the pleading of the Complainant. To decide the case,reference has been made to certain judicial pronouncements on such generic issue. Thecases referred to are Mrs. Agne’s D’Mello Vs. Canara Bank and Consumer Education andResearch Society and Another Vs. LIC of India [ I (1993) CPJ 128 (NC) ]. Based on aboveobservations, it is held that merely on technical plea of time bar, denial of a claim is unfair.Respondent to pay Paid-up Value (with Bonus if any) to the rightful Claimant.Ahmedabad Ombudsman CentreCase No. LIC / 2 / 143Shri Rakshit R. MehtaVs.Life Insurance Corporation of IndiaAward Dated 29.10.2004DLA, wife of Complainant. Her Policy started with risk date effective from 20.3. 2002. On14.9.2002 she died. Claim repudiated on the ground of suppression of fact. Complainantsubmitted that before accepting the Proposal, DLA was medically examined by the PanelDoctor of the Respondent. Further, the DLA had disclosed in the Proposal Form that shehad hemophagia in 1992 and her consequent problem in movement of Right side of thebody. Apart from these disclosed problems of DLA there was nothing significant to bedisclosed. The death was caused by a sickness in Perianal area which was detected in July2002 only. Respondent submitted that the DLA was suffering from Gastro - intestinalinfection and was treated for 2 days by Dr. Deliwala and this fact was not disclosed by theDLA. Documents and submissions perused. For proper understanding the gravity ofomission of gastro - enteritis, referred to the Medical Dictionary of the British MedicalAssociation and observed that it is absolutely a commonplace illness. Next point examinedis that whether such omission of common diseases are to be taken as the base for deathclaim repudiation ? In this connection, a reference is made to the case [I (1998) CPJ 45(NC)] wherein the generic observation made by NC is “it is not that the Assured is requiredto disclose casual ailment” and that “the sickness, ailment which was required to bedisclosed is that with refence to serious disorders in health”. Next document perused is thePathological Report and observed that the perianal Hematoma with Abscess that the DLAsuffered from preceding to death was detected in July 2002. The Investigation Report ofthe Respondent’s own officer also could not bring out any negative Report towards thegenuineness of the claim. Respondent gave no weight age to the Investigation Report, butmore weight age was given to mere omission in non - disclosure of common illness as asole ground for repudiation. Claim allowed for full SA with 8 % simple interest.Ahmedabad Ombudsman CentreCase No. 21 - 001 - 0068
Mr. Ramesh D. MakwanaVs.Life Insurance Corporation of IndiaAward Dated 02.11.2004Repudiation of death Claim. DLA, wife of Complainant. Risk accepted on 15.5.2002 - LAdied on 12.4.03 due to Rheumtic Heart Disease. The point taken for determination iswhether the DLA was suffering from Rheumatic Heart Disease and whether this fact wasdisclosed in the Proposal Form while proposing for insurance. Documents perused. It isobserved from the certificate of Attending Medical Officer, Civil Hospital, Bhavnagar thatthe case history was noted as K / C / O / RHD. Suppression of material fact established.Compliant dismissed without any relief to the Complainant.Ahmedabad Ombudsman CentreCase No. 21 - 001 - 0205Mr. Manubhai R. BhoiVs.Life Insurance Corporation of IndiaAward Dated 18.11.2004Complainant’s Son who held Policy on his life died on 11.4.03. The Policy commenced on28.11.02. Claim repudiated on the ground of suppression of facts. The point taken fordetermination was whether suppression of fact is proved and if so, was it material forunderwriting decision. Documents and submission perused. Its is observed from the COHTof Mulgibhai Patel Urological Hospital that the DLA was admitted in the said Hospital on29.1.03 due to Oedema feet and the duration of the complaint is indicated 4 months andthe diagnosis was Chronic Renal Failure. Hence, the suppression is proved by theRespondent. It is also observed from the documents that theh / o disease was reported by the Complainant itself to the Treating Doctor, but theComplainant did not disclose the fact of ailment of his 12 year old son, in the ProposalForm. Repudiation upheld.Ahmedabad Ombudsman CentreCase No. 21 - 001 - 0138Smt. Y. D. SolankiVs.Life Insurance Corporation of IndiaAward Dated 06.12.2004Complainant’s husband was having 2 Insurance Policies. One Policy revived on 4.12.02and the second one completed on the basis of Medical Report and personal statement onthe aforementioned date itself. LA died on 17.12.03. Respondent repudiated the Claim onthe ground that the DLA was suffering from Cancer prior to revival of the Policy, the factwhich was not disclosed. Respondent submitted Claim Form B & B1, COHT, all from CivilHospital, Surat, a Certificate of Dr. Jayesh Shah and History Sheet and Records fromGujarat Cancer & Research Institute in support of their contention. The Respondent statedin the repudiation letter that they have indisputable evidence to prove that the DLA tooktreatment for Cancer prior to revival of Policy on 4.12.02 and also treated for Cancer inAugust 2002 and special investigations were also made on 30.7.2002. The point ofdetermination in this case is whether the Respondent could indisputably establish theaforesaid allegations as per documents submitted by them. It is observed that Dr. JayeshShah’s Certificate never stated that any treatment was administered to the DLA. Whenasked to the Respondent to identify any document to prove that the DLA took treatment for
Page 3: of treatment for urinary tract infe
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 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
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In short, LIC has no valid ground a
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Smt. Lakshi DeviVs.Life Insurance C
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Findings : It appears that on the s
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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
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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
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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
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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
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eceived on 12.08.04 by the company,
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Life Insurance Corporation of India
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