Death Claim - Gbic.co.in

DLA died on 26.01.2003 due to DM Chronic Renal Failure Then, the death claim waspreferred by Complainant with the Respondent, which was repudiated by theRespondent on the grounds of suppression of material facts regarding health of DLA atthe time of revival. Then the complainant had referred the case to Respondent’s ClaimsReview Committee for reconsideration which was also upheld by them on 06.06.2006.The claimant preferred a complaint to this Office.Observations of Ombudsman: I have gone through the materials on records andsubmissions made during hearing and summaries my observations as follows:There is no dispute that the Policy No. 351488035 was issued to DLA by theRespondent on 28-08-1999; the same was revived on 15-12-2001 and death of DLAoccurred on 26-01-2003.During hearing, the complainant informed that the DLA was not suffering from anydiseases and was in good health at the time of revival of the policy in question.During hearing, the Respondent contended that The Case History Sheet of BhopalMemorial Hospital also reveals the History of Hypertension since 1995, DiabetesMellitus since 1995,CAD since 1999 etc. Dr. Quasim Ali Anjum has in claim form ‘ B ‘certified the primary cause of death as “ Cardio-respiratory failures “ and secondarycause of death is as “Diabetes c Chronic Renal Failure” However the history ofaforesaid diseases/ailments were not mentioned by the DLA in the DGH dated04.12.2001 submitted for revival of the policy. The DLA was diagnosed for aforesaiddiseases/ailments and hence the claim was repudiated due to concealment of materialfacts regarding health of DLA. Had the DLA’s ill health and treatment details beenbrought to the knowledge of the Respondent during revival in DGH submitted by theDLA, the underwriting decision of the Respondent would have been different.On scrutiny, it is observed from The Claim form B, DGH, ECG Report of NiramayHospital and Ayushman Hospital dated 06.01.2001and 06.12.2000 respectively, HistorySheet of Bhopal Memorial Hospital, Angiography Report dated 14.02.2001 of HinjujaHospital, letter dated 10.08.2005 of Dr.Rajeev Madan. that it was a known case ofhypertension since 1995, Diabetes Mellitus since1995 and coronary artery diseasesince June 1999.It is further observed from Claim form B issued by Dr. Quasim Ali Anjum 133,M.P.Nagar- Zone-II, BHOPAL has in claim form ‘ B ‘ certified the primary cause ofdeath as “ Cardio-respiratory failures “ and secondary cause of death is as “Diabetes cChronic Renal Failure” whereas in the Declaration of Good Health (DGH) report signedby DLA on 15-12-2001 during revival shows that the he had never suffered from anyailment whatsoever in the past and that he was absolutely keeping normal health.Thus, from the foregoing facts it is clear that there is a direct nexus between the causeof death and the ailments suffered by DLA. Hence, it is clear that the DLA intentionallysuppressed the material facts regarding health to the Respondent at the time ofreviving the policy in question.Insurance is a contract of Utmost Good Faith where both parties are required todisclose all the material facts. No party can be allowed to gain any undue advantage bysuppressing any fact. In the instant case, there are sufficient evidential proofs to showthat the DLA was already suffering from serious ailments but suppressed the same inthe DGH report at the time of revival. Thus, the DLA has misled the Respondent by notproviding vital information regarding his health at the time of revival and hence theRespondent was not able to take proper underwriting decision. Had the facts beenbrought to the knowledge of the Respondent, its underwriting decision would have beendifferent.