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Cancer, they admitted that except recording of consultation / opinion there is no evidenceto prove the same. The History Sheet and records of Gujarat Cancer & Research Institutealso did not mention anything that the DLA was treated for Cancer one year before fromAugust 2003. The inhouse investigation conducted by the Branch Manager also concludedhis Report with the comments that the Claim is genuine and need to be admitted.Reference also has been made to judicial pronouncements in I [ (1998) CPJ 45 (NC) ] andIII (1999) CPJ 43. Held that no evidence could be submitted by the Respondent to provethat the DLA took treatment for Cancer prior to revival of Policy on 4.12.2002. Repudiationset aside. Respondent to settle the claim under both the Policies alongwith 8 % interestcomputed from the immediate subsequent date when 6 months expired since lodging theClaim.Ahmedabad Ombudsman CentreCase No. LIC / 2 / 149Smt. Puriben ParmarVs.Life Insurance Corporation of IndiaAward Dated 7.12.2004Complainant’s husband was the Holder of an LIC Policy. He died in Sept. 2001.Complainant lodged claim, but it was repudiated on the ground of suppression of facts inthe Proposal dated 31.1.2000. Complainant was not called for Hearing since the documentssubmitted from her side was considered enough. Respondent was asked to list out thedocuments relied upon by them in effecting repudiation. He listed out COT, COHT, ClaimForm - B and Leave Statement. Documents perused. Certificate of Sick Leave took by theDLA has not considered as a prime evidence since it is a wide spread practice amongstStaves to take SL under the pretext of fictitious diseases, particularly because neither thecopy of Application nor the specific ground for taking leave could be produced. It isobserved that in any one of the Documents such as COT, Claim From - B, COHT, theduration of the DLA’s disease had been mentioned earlier than - 14.1.2001. The inhouseinvestigation conducted by the Respondent also could not bring out any precise orassertive conclusion. Suppression of facts is not proved. Respondent to pay full SA with 8% simple interest to the Complainant.Ahmedabad Ombudsman CentreCase No. 21 - 001 - 0248Smt. Ratuben ChaudharyVs.Life Insurance Corporation of IndiaAward Dated 14.12.2004Complainant’s Husband took the Insurance Policy on 15.1.03. He died on 13. 4.03. Claimrepudiated on the grounds of alleged incorrect statement and withholdment of materialinformation regarding state of health o the DLA. Documents and submissions perused. It isobserved from the COHT and MAC that the DLA was Heart Patient and had Heart Attack afew years back. As regards the responses given by the DLA in the Proposal Form againstQuestions regarding Heart Disease and Hypertension, it is opined that the DLA’s negativeanswers have vitiated the underwriting decision of the Respondent. The primary cause ofDLA’s death being Inferior Wall M. I. C Hematoma, it had close nexus with the RadiologicalFindings dated 12.7.1997 done by Uramil Heart & Lung Centre. Repudiation Upheld.Ahmedabad Ombudsman Centre
Case No. 21 - 001 - 0249Mr. K. D. DodiyaVs.Life Insurance Corporation of IndiaAward Dated 27.12.2004Complainant and his Spouse held a Joint Life Policy. Proposal was accepted on OR withDAB subject to Clause 4 (b). Wife died by electric shock on 11.1.03. Claim lodged.Respondent decided to refund the premium received, since the Claim was arisen as aresult of stipulated contingencies including “Accident other than an accident in a publicplace”. Complainant was not called for Hearing since the documents submitted by him wereadequate. Heard the Respondent and perused the documents. It is observed that there areenough evidences to prove conclusively that the death was by accident. The only infirmitythat affected the death from the stand point of claim settlement is that it did not take placein a public place in the strict sense of the term attracting the provisions of ExclusionClause 4 (b) literally. Respondent submitted that this Clause was introduced by theirActuarial Department’s Circular did. 8.3.1985 to prevent from manifold who take premediatedPolicy on the lives of house - wives and enrich themselves by enacting dubiousaccidental death of women. Further observed that the death by accident was not doubtedand the Investigation Officer also confirmed the death by electric shock when switched onthe water pump and concluded the claim as genuine. The internal noting of the Respondeatalso recommended that the claim may be admitted for sum Assured without going byClause 4 (b) literally. The directions of Hon’ble courts to follow “Main Purpose of Rule” inthe Cases of [ 187 ACJ 411 (SC) ] and [ AIR 1996 SC 2054 ] have also referred.Respondent to pay SA and Bonus alongwith 8 % simple interest.Ahmedabad Ombudsman CentreCase No. 21 - 001 - 0254Smt. Zahedabanu I. RajaVs.Life Insurance Corporation of IndiaAward Dated 27.12.2004Repudiation of Death Claim - Claim arose from the death of Complainant’s Husband.Respondent repudiated the claim due to withholdment of correct information andsuppression of material fact committed by DLA regarding his state of health at the time ofproposing for insurance. The pleading of the Complainant was that the DLA experiencedchest pain and subsequently died by Heart Attack. Examined the evidences adduced by theRespondent in support of their repudiation. It is observed that there are Exhibits submittedby the Respondent such as Medical Report from Bharuch Hospital, MAC issued by Dr.Arvind lyer and COHT from Bharuch Hospital, all revealed that the DLA was suffering fromHeart Disease and Diabetes Mellitus and had taken treatment in May 2001 in BharuchHospital. It is also observed that the DLA did not disclose the fact of his state of health inthe Proposal Form. Repudiation upheld.Ahmedabad Ombudsman CentreCase No. 21 - 001 - 0203Shri Mukeshkumar C. ShahVs.Life Insurance Corporation of IndiaAward Dated 30.12.2004
Page 3 and 4: of treatment for urinary tract infe
Page 5: Mr. Ramesh D. MakwanaVs.Life Insura
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
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
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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
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
Page 83 and 84:
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
Page 119 and 120:
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
Page 203 and 204:
Certificate dated 3.3.03 issued by
Page 205 and 206:
were not disclosed. Under the circu
Page 207 and 208:
the deceased life assured withheld
Page 209 and 210:
his health at the time of effecting
Page 211 and 212:
history of Appendectomy 15 years ba
Page 213 and 214:
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
Page 221 and 222:
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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