Death Claim - Gbic.co.in

The policy was issued under medical scheme and risk accepted with an extra premiumfor elevated liver enzymes.The insurer rejected the claim stating that the LA did not disclose about history of livercirrhosis which was diagnosed way back in 3/2001.The LA was treated in Mallya Hospital at Bangalore in 03/2001 for enteric fever. Theclaim was rejected by the insurer based on the discharge summary report dated19.03.2001 given by Mallya Hospital in which the radiologist gave an impression ofcirrhosis of liver with portal hypertension. As the final cause of death was due to thesame health problem, the insurer rejected the claim.The medical reports submitted by the insurer as part of their evidence were referred toa specialist doctor at Hyderabad for expert opinion. The doctor gave an opinion thatelevated liver enzymes does not conclusively prove existence of cirrhosis of liver.However, the proposal was accepted after examination of the LA by a medical man ofthe insurer. The medical examination report contains two parts. One part of the reportwas completed by the LA and the second part by the Medical Examiner. In his part, theLA mentioned about the treatment taken in Mallya Hospital in 03/2001. The MedicalExaminer of the Insurer also made a reference to the said report. The insurer insistedof collecting the information at that time itself, chose to accept the proposal with an‘extra premium’. Allegation of the insurer is not proved beyond doubt. Hence thecomplaint was allowed.Hyderabad Ombudsman CentreCase No. : L-21-001-0249-2006-07Sri Jitendra BagadeVsLife Insurance Corporation of IndiaAward dated 15.11.2006Head Notes: Death claim rejected by LIC for reasons of incorrect information furnishedin the proposal – Rejection action upheld.FACTS OF THE CASE(Late) Maruti S/o Dattatreya Bagade obtained Pol.No.660360599 for Rs.75000/- underTable 91-20 from Gulbarga-I Branch of LIC, Raichur Division. The LA submitted aproposal dated 16.05.2005 and the policy commenced on 14.05.2005. The LA died on18.05.2005 allegedly due to chest pain. Sri Jitendra Bagade is the brother of the DLAand also the nominee.Finding the claim to occur in just 3 days from the proposal date, LIC enquired into themerits of the claim. Their enquires revealed that the LA had another policy bearingno.660888853 for Rs.100000/-. The LA’s wife Smt. Geetha was nominee under thatpolicy and death claim was settled in her favour. Particulars of old policy were notfurnished in the proposal for the current policy. As per old policy, the LA’s age wasadmitted taking DOB as 01.06.1969 on the basis of a school certificate, whereas a selfdeclarationof age was given in the current policy proposal and DOB was shown as02.04.1971. Other details relating to family history also deferred from old policy.Additionally the style of signature in both proposals deferred considerably.The insurer rejected the claim for reasons of non-disclosure of previous policy andthereby suspected the bonafides of the claim under current policy.The insurer contended that non-disclosure of previous policy made them to issuecurrent policy readily. Had they come to know about existence of another policy forRs.1 lakh, they would have enquired into the reasons for discrepancies in all material