Death Claim - Gbic.co.in

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SBI Life Insurance Co. Ltd.Award dated 20.10.2006Head Notes: Repudiation of death claim by SBI Life under Group PolicyNo.82001128307 – Conclusive proof of treatment taken prior to joining the scheme notgiven by the insurer – Hence complaint allowed.FACTS OF THE CASE(Late) Smt. Meesala Anantha Lakshmi W/o M. Govindarajulu, became a member ofGroup Life Insurance Scheme of SBI Life’s Super Suraksha Policy w.e.f. 23.07.2004.The member - life assured submitted a ‘Good Health Declaration’, at the time of joiningthe scheme and the scheme meant for the benefit of accountholders of SBI and itsmember banks. The sum assured is Rs.1 lakh for natural death. The life assured diedon 24.09.2005 allegedly due to cancer. The claim was refused by the insurer on theground that the DLA was suffering from cancer even prior to her enrolment into thescheme.The insurer produced Xerox copies of outpatient ticket no.143216 issued by KGH,Visakhpatnam. The date of consultation was not very clear on the Xerox copy. Theinsurer claimed that it refers to 14.06.2002, while the complainant claimed that thedate was 14.06.2005. The insurer could not substantiate his claim by submitting furtherevidence. Hence benefit of doubt was given in favour of the complainant and thecomplaint was allowed.Hyderabad Ombudsman CentreCase No. : L-21-002-0196-2006-07Smt. ShobhaVsSBI Life Insurance Co. Ltd.Award dated : 23.10.2006Head Notes: Repudiation of death claim under Group Super Suraksha Policy on groundof suppression of material facts – Complaint Dismissed.FACTS OF THE CASE(Late) Pratap Singh became a member of the ‘Super Suraksha’ Group Policy issued bySBI Life. The LA because a member of the scheme w.e.f. 29.1.2005 and he died on26.04.2005, reportedly due to Anasarca and Chronic Renal Failure. The life assuredbecame a member of the group policy on the strength of a ‘good health declaration’.During the course of enquires made by the insurer, it was revealed that the LA wassuffering from TB for about six years. The insurer obtained medical record from doctorswho have treated the DLA during the lifetime, who have certified about existence of TBprior to membership and about personal habits of alcoholism and smoking.Finding the declaration of good health submitted by the DLA to be false, the insurerrepudiated the claim.The evidence produced the insurer clearly showed that the LA was suffering from TBprior to membership. As the final cause of death has a bearing on the previoustreatment, the action of the insurer was upheld. In effect the complaint was dismissed.Hyderabad Ombudsman CentreCase No. : L-21-001-0218-2006-07Smt. A. SarojaVs
Life Insurance Corporation of IndiaAward dated : 26.10.2006Head Notes: Repudiation of death claim on grounds of suppression of material facts –Ex-gratia of Rs.10000/- allowed.FACTS OF THE CASEPolicy No.652502783 for Rs.100000/- was taken on the life of (late) A. Gadilingappa,R/o Kalyandurg, Andhra Pradesh. The policy commenced on 15.11.2001 under 75-20plan with quarterly premium of Rs.1730/-. The policy passed after payment of 11quarterly instalments (up to 5/2004). It was revived on 18.07.2005 on the strength of aDGH and four quarterly instalments were paid at revival time. The LA died on21.09.2005 due to kidney failure.The complainant is the nominee under the policy. LIC investigated the claim andrejected it as they found out that the LA had treatment for chronic renal failure prior torevival of the policy. They obtained a certificate from Dr. A. Gopal Rao of Rayadurgrelating to the treatment taken by the DLA prior to revival. The LA died in a hospital atBangalore on 21.09.2005 due to chronic nephropathy Syndrome. As the insurer provedin a conclusive way about existence of disease prior to revival of the policy, thecomplaint was found to be devoid of any merit. However, considering the economicstatus of the complainant, it was decided to order an ex-gratia of Rs.10000/-.Hyderabad Ombudsman CentreCase No. : L-21-001-0120-2006-07Sri B.C. BasavarajuVsLife Insurance Corporation of IndiaAward dated 29.10.2006Head Notes: Death claim repudiated by LIC for reasons of suppression of facts –complaint rejected.FACTS OF THE CASE(Late) Smt. Gowramma W/o Sri B.C. Basawaraju (Complainant) obtained a policyno.61414310 for Rs.50000/- sum assured from Madhugiri Branch of LIC, BangaloreDivision-1. The policy commenced on 20.10.2003 under Table 14 for a 15-year period.The life assured died on 15.05.2004 allegedly due to heart complaint at her residence.As the LA died in about 7 months from commencement of the policy, the insurerenquired into the merits of the case. As per their enquires the LA was under treatmentfor Diabetes Mellitus, Hypertension for about four years before issue of the policy. LICobtained F.No.5152 from Dr. Nissar Ahmed, MBBS, Chitradurga to that effect andrepudiated the claim.During the personal hearing session, the complainant did not deny treatment takenfrom the said doctor but contended that treatment was only for minor ailments. Thecomplainant further contended that BP and Sugar were at negligible levels. He furthercontended that the LA developed sudden chest paid after quarrelling with house-maidon the fateful day.The evidence produced by LIC corroborate with the past history of treatment taken forDM & HTN. Hence, repudiation action was considered to be in order and the complaintwas rejected.
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Repudiation of Claim for Payor’s
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Award Dated : 27-11-2006Repudiation
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The Complainant’s husband held a
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sniped at Utmost Good Faith that fo
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In view of the above, the decision
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concealment of material facts regar
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The complaint was registered and ne
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he had never suffered from any ailm
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from Chronic Hepatitis c Cirrhosis.
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same till death claim arises. The R
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adhikar ewam Rin pustika ” for Ag
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10 days from date of commencement a
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grounds of suppression of material
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the claim for the reason “Suppres
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It is observed from the Medical cer
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It has also not been verified by th
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disbursement of salary as reported
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There was no dispute that the DD fo
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proposal the contract remains uncon
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the claim stating that her son bein
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states that no common poison was fo
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the Insurer on the ground that the
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On perusing the documents it is obs
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application for insurance on 22.12.
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preferred a claim with the Insurer.
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the time of taking the policies. In
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in January 2000. The policy was rev
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Subsequently he was referred to Tir
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All the spells of medical leave hav
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In the hearing, the complainant sta
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KTVR Group Hospital due to “Hepat
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Chennai Ombudsman CentreCase No. :
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He was also on leave during 11.04.2
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Life Insurance Corporation of India
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Chennai Ombudsman CentreCase No. :
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found in the body. It was further r
Page 77 and 78: family doctor. He admitted that his
Page 79 and 80: Smt.S.Shanthi obtained a life insur
Page 81 and 82: act. She stated that as per the sta
Page 83 and 84: evival was almost like a fresh cont
Page 85 and 86: contended that the deceased life as
Page 87 and 88: Sri J. Hussain Mohammed submitted a
Page 89 and 90: and his wife was sitting after her
Page 91 and 92: In the hearing the complainant stat
Page 93 and 94: VsLife Insurance Corporation of Ind
Page 95 and 96: Jodhpur on 11.11.2002 and was disch
Page 97 and 98: He had concealed the material fact
Page 99 and 100: They further needed claim forms No.
Page 101 and 102: on life of her husband Late Shri. R
Page 103 and 104: Delhi Ombudsman CentreCase No. : LI
Page 105 and 106: The representative from Life Insura
Page 107 and 108: 3 months and 14 days of taking poli
Page 109 and 110: 09.06.2003 and the proposal was sub
Page 111 and 112: Leukemia. Bone Marrow Report dated
Page 113 and 114: Thus, he withheld facts and was gui
Page 115 and 116: questions provided in item no.11 of
Page 117 and 118: the claims excepting the present on
Page 119 and 120: The submission of LIC is that the p
Page 121 and 122: LIC that other two policies of Sum
Page 123 and 124: Branch Office of LICI. It is stated
Page 125 and 126: We have considered the photocopies
Page 127: On the circumstances aforesaid, it
Page 131 and 132: nos.722662607 for Rs.50000/- and 72
Page 133 and 134: information. The insurer also suspe
Page 135 and 136: The claim was rejected by LIC stati
Page 137 and 138: Facts of the Case: (Late) G.Appa Ra
Page 139 and 140: Head Notes: Life assured availed a
Page 141 and 142: in English, which suggest that he i
Page 143 and 144: LIC about usage of herbal medicines
Page 145 and 146: age proof. She requested for settle
Page 147 and 148: the owner of the opposite vehicle i
Page 149 and 150: action was found to be based on pro
Page 151 and 152: certificate issued by one Dr.H.R.De
Page 153 and 154: suffering from disease prior to rev
Page 155 and 156: establish that the LA failed to dis
Page 157 and 158: The complaint under Rule 12(1)(b) r
Page 159 and 160: not be blamed entirely. But, the mi
Page 161 and 162: Life Insurance Corporation of India
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Page 165 and 166: Ltd and expired on 30.09.04. Theref
Page 167 and 168: Kotak Mohindra Old Mutual Life Insu
Page 169 and 170: We may mention that the insurance c
Page 171 and 172: evidence to prove that the DLA was
Page 173 and 174: The insurance company in their self
Page 175 and 176: time of taking the policy and that
Page 177 and 178: the required papers and hence there
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their own guidelines can consider t
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the contract was not complete and e
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and, therefore, she interpreted tha
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cheque No.258433 dt.20.2.2007. Prob
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We were unable to modify the order
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certificates submitted by the claim
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Smt. Phoolpatti had lodged a compla
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dispute the will but contended that
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Jaiswal who in their report confirm
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treated the person but since the si
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31.03.05/11.04.05 issued under the
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Shri Sarvjit Gupta had lodged a com
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complainant awarded payment of full
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with him during the period 02.03.04
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Award dated 31.02.2007Smt. Shakunta
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asis of which proposal was complete
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Consultation/Treatment as proof of
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Smt Shantona Kanaiya Ghosh had take
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ody with altered behavior for few m
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Mumbai Ombudsman CentreCase No. : L
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Diabetes Mellitus since 20 years an
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Jhatingrao Gaikwad to pursue the ca
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into consideration, it would be rea
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Mumbai Ombudsman CentreCase No. : L
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