Death Claim - Gbic.co.in

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Facts of the case and decision : (Late) G.N.Satyanarayana obtained three policiesbearing nos. 611395848; 611395892; 61278821 from Pavagada and Tumkur branchesof LIC. The sum assured under the policies are Rs.25000; 50000 and 22000respectively. The policies commenced on 15.12.1999; 28.2.2000 and 28.3.2000respectively. The life assured died on 18.8.2000 and the complainant claimed moneysfrom LIC on 12.5.2005. LIC repudiated the claim under the policies stating that theclaims were barred by limitation and that the policies were obtained by suppressingmaterial information about the state of health of the life assured at the time ofproposals. The insurer contended that due to delayed intimation, they were denied anopportunity of getting full information about the cause of death of the LA and otherdetails. The insurer contended that as per their enquiries, the LA died due to suicideand he suffered psychiatric problems for about five years before death. Theycontended that the LA was treated by Dr. M.T. Satyanarayana, Head, PsychiatryDepartment, Siddartha Medical College, Vijayawada during the years 1994 to 1999. Allpolicies were taken in quick succession to secured monetary gain and reference aboutprevious policies was not furnished in the proposals given. During the personal hearingsession, the complainant admitted that her husband was treated by the doctor whomthe insurer was referring to. As the circumstantial evidence pointed towardssuppression of material information, the complaint was dismissed.Hyderabad Ombudsman CentreCase No. : L-21-001-0256-2006-07Sri K. RaviVsLife Insurance Corporation of IndiaAward Dated : 29.12.2006Head notes: Repudiation of death claim. Complainant gave a disclaimer initiallyagreeing to withdraw his claim. Subsequently he changed his stand and claimed thathe signed only on blank affidavit. Complaint allowed partially to the tune of refund ofpremium on ex-gratia basis.Facts of the case and Decision : The complainant is the brother of the DLA and theNominee under the disputed policy. (Late) K.Venkateswar Rao R/o Bandipalemobtained a policy bearing no.673091348 for Rs.1,00,000 sum assured from Jaggiahpetbranch of LIC. The policy commenced on 23.1.2004, under 14-16 Plan and with anannual premium of Rs.6344/-. The LA died on 14.4.2004 allegedly due to sunstroke asper the complainant. This policy was obtained while reviving a previous policy no.671774318 for Rs.50000 sum assured on 23.1.2004. As the previous policy had run fora longer duration and as the nominee under previous policy was the LA’s mother, LICsettled claim under the Rs.50000 policy and they repudiated claim under the latestpolicy. As per enquiries of LIC, the LA died due to AIDS, but they could not secure anydocumented evidence to that effect. As a part of their enquiry they obtained adisclaimer from the complainant, which was sworn before a Notary Public, in which thecomplainant declared that the disputed policy was obtained by his deceased brother onthe basis of fraudulent information given in proposal.The complainant contended that his brother died suddenly due to sunstroke and notdue to AIDS as alleged by the insurer. He further claimed that he signed the sworndeclaration thinking that it was a routine paper for settlement of the claim. Thecomplainant pleaded that he does not understand English, the language in which thenotarized statement was prepared and that he was misled by the Agent of LIC. All thecorrespondence with this office regarding the complaint was made by the complainant
in English, which suggest that he is taking the guidance of some knowledgeable personwhile dealing with the claim. Hence the contention of the complainant was notaccepted. However, considering the other pleadings of the complainant regardingfinancial background, it has been decided to order an ex-gratia payment in the form ofrefund of the first premium.Hyderabad Ombudsman CentreCase No. : L-21-009-0241-2006-07Smt. Veena paiVsBajaj Allianz Life Insurance Co. Ltd.Award Dated : 03.01.2007Facts of the case and Decision: (Late) Sri Viswanath Pai obtained a policy bearingno.0012235357 for Rs.1 lakh sum assured from Bajaj Allianz Life Inusrance Co. undertheir ‘Unit Gain Main Cover’ plan with the commencement date of 27.10.2005. The lifeassured died on 9.11.2005 i.e. within 11 days from the commencement date due tocarcinoma of lungs, while undergoing treatment in KMC Hospital, Mangalore. As perthe running case sheet obtained by the insurer, the LA died primarily due tobroncheogenic carcinoma and the duration of illness was recorded as five months. Asper case sheet, the LA was suffering from breathlessness for 5 months and cough withexpectoration for five months before death. The LA was also diagnosed to be sufferingfrom diabetes a month before his hospitalization for terminal illness and he was on tab.Glimiperide. The LA also was known to have a personal history of TB, HT, bronchialasthma and ischemic heart disease as per KMC Hospital record. During investigations,the insurer found out that the LA’s father suffered from cancer of colon and the LA’sbrother died of leukemia. As the LA did not disclose his personal history of persistentcough for five months and family history of cancer etc. the claim was repudiated by theinsurer through their letter dated 6.6.2006. Section 45 of the Insurance Act, 1938 is notapplicable.A personal hearing session was held on 22.12.2006 at Bangalore in which both sidesparticipated. The insurer submitted relevant hospital records. The complainantcontended that her husband did not know that he was suffering from symptoms ofcancer when he made the proposal on 25.10.2005. She claimed that the corporateagent of the insurer knew her husband very well and certified that he was in goodhealth at the time of proposal. She contended that her husband came to know of hisdisease on 6.11.2005 and pleaded for admission of the claim. She referred the orderdated 3.10.2006 of NCDRC in Revision Petition no.1696 of 2005 in the case of PraveenDamani Vs. oriental Insurance Co. Ltd. Wherein it was held that the claim was valid ifthe insured was unaware of the pre-existing disease.After examining the evidence placed on record, the contention of the insurer wasaccepted and the repudiation action was upheld. However, as the premium paid by theLA contained some investment portion, the insurer was directed to refund theaccumulated value of the savings portion of the premium.Hyderabad Ombudsman CentreCase No.L-21-002-0275-2006-07Sri M. RajeshVsSBI Life Insurance Co. Ltd.Award Dated : 31.01.2007
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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
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family doctor. He admitted that his
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Smt.S.Shanthi obtained a life insur
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act. She stated that as per the sta
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evival was almost like a fresh cont
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contended that the deceased life as
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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 and 128: On the circumstances aforesaid, it
Page 129 and 130: Life Insurance Corporation of India
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: Head Notes: Life assured availed a
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
Page 163 and 164: hypertensive before the inception o
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
Page 179 and 180: their own guidelines can consider t
Page 181 and 182: the contract was not complete and e
Page 183 and 184: and, therefore, she interpreted tha
Page 185 and 186: cheque No.258433 dt.20.2.2007. Prob
Page 187 and 188: We were unable to modify the order
Page 189 and 190: 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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Death Claim - Gbic.co.in

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