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Head Notes: Life Assured obtained a housing loan from SBI and joined a groupinsurance policy. The LA was murdered and the insurer rejected the claim on the pleathat the Nominee under the policy was involved in the murder of his mother and hencehad no insurable interest. After a personal hearing the insurer was asked to wait forthe final outcome of the criminal case from a competent court of law.Facts of the case and Decision : (Late) Smt. M.Vajaya Lakshmi borrowed a housingloan of Rs.6 lakh from SBI, Yellareddyguda branch, Hyderabad and joined the ‘SuperSuraksha’ Master policy meant for the borrowers of housing loans from SBI and itsassociated banks. The LA submitted a proposal- cum- Good Health Declaration formdated 29.8.2003 to join the policy and paid a single premium of Rs.16596.00.Shenominated her son Mr. M.Rajesh under the provisions of Section 39 of the InsuranceAct, 1938. As per records, the LA was murdered on 6.11.2005 and the prime suspectsin the murder are the LA’s son and husband. The contents of the FIR indicate that theLA was engaged in immoral traffic, which finally led to her murder by her own son andhusband.The insurer rejected the claim on the ground that the LA obtained an ex-parte divorceorder, which is suspicious. The insurer suspected moral hazard in the transaction andas the nominee was directly involved in the crime as per FIR, they rejected the claim.During the personal hearing session, the Nominee/Complainant pleaded innocenceabout the murder and stated that another woman also was murdered along with hismother on the same day and in the same premises. He contended that the police havenot completed their investigation and a charge sheet is yet to be filed.Considering the contentions made by both sides, it was felt that the repudiation actionwas taken by the insurer in a hasty manner. Hence the insurer was directed to reviewtheir decision after receiving a final judgment from a competent court of law.Hyderabad Ombudsman CentreCase No.L-21-001-0344-2006-07Smt. B.SatyavathiVsLife Insurance Corporation of IndiaAward Dated : 31.01.2007Facts of the case and Decision:(Late) Sri B.Satyam Naidu, a resident of Booripet obtained a policy bearingno.693547048 for a sum assured of Rs.30,000 from Rajam branch of LIC. The policycommenced on 28.12.2004 under ‘Janaraksha Plan’ (T No.91-20) with a yearlypremium. The LA died on 31.1.2005 due to jaundice and as the claim was a very earlyclaim occurring in just one month from the commencement of the policy, LICinvestigated into the bona fides and repudiated for reasons of non-disclosure ofmaterial facts. As per the evidence produced by LIC, the LA underwent a Barium Mealtest in MIMS (Maharaja Institute of Medical Sciences), Nellimarla on 21.2.2004 withI.P.No.627 and was diagnosed to be suffering from stomach cancer.A personal hearing into the complaint was held on 24.1.2007 at Hyderabad and bothsides attended the session. The complainant did not totally deny treatment taken fromMIMS, Nellimarla, but she contended that her deceased husband took treatment forstomach pain. She further stated in one of her letters addressed to LIC that herhusband took herbal medicines for treatment of jaundice just one week before deathand was cured of the disease. Considering the duration of the policy, nature of diseasesuffered by the LA during his terminal illness, information given by the complainant to
LIC about usage of herbal medicines, it became evident that the LA was not in goodhealth at the time of making the proposal. Hence, the decision of the insurer wasconsidered to be justified. However, considering the appeal of the complainant that shehails from a very poor family, it was decided to order an ex-gratia payment ofRs.10,000 to the complainant.In essence, the complaint was allowed partially.Hyderabad Ombudsman CentreCase No.L-21-001-0331-2006-07Sri G. MattiahVsLife Insurance Corporation of IndiaAward Dated : 31.01.2007Facts of the Case and Decision:(Late) Smt. G. Anjamma obtained a policy bearing no.670020130 for Rs.50,000 sumassured from Narasaraopet branch of LIC, with the commencement date of 20.4.2005.The LA nominated her brother Sri G.Mattiah as the beneficiary under Sec.39 of theInsurance Act, 1938. The LA was engaged in handloom weaving and was aged 36years at the time of proposal. The LA died on 2.10.2005 and claim occurred in about 5month’s time. As per claim papers submitted to LIC, the LA died due to spinal cordinjury. The claim was rejected by LIC through their letter dated 7.12.2005.A personal hearing session was held on 20.12.2006 at Hyderabad in which both sideswere represented. The insurer contended that the LA was not healthy at the time ofproposal in 05/2005 and she suffered a bone fracture in 03/2005. As per the insurer,the LA was admitted into Susmita Ortho & Trauma Care Hospital, Narasaraopet on12.4.2005 with a history of weakness of all four limbs since one month. She wasdischarged from that hospital on 21.4.2005 in a very bad condition. The insurerproduced a certificate in their form B-1 in which the last medical attendant certified thatthe LA was suffering from Quadriparesis due to cervical cord compression and thedoctor did not mention about injury anywhere in his statement.The complainant/Nominee contended that the LA suffered spinal cord injury after anaccidental fall on 10.7.2005, which finally led to her death on 2.10.2005. He contendedthat the period of treatment was from 10.7.2005 to 20.7.2005 for the injury and notbefore commencement of the policy.Section 45 of the Insurance Act, 1938 is not applicable as the claim was rejected withina period of 2 years from the date of risk on grounds of suppression of material factsrelating to the health condition of the LA.After examining the evidence placed on record, it was decided to uphold therepudiation action taken by LIC. The case was dismissed without any relief.Hyderabad Ombudsman CentreCase No.L-21-009-0315-2006-07Smt. Ch. DurgammaVsBajaj Life insurance Co. Ltd.Award Dated : 31.01.2007Facts of the case and Decision:(Late) Chakka Pitchiah obtained a policy bearing no.0008524952 for a sum assured ofRs.2,50,000 from the insurer under ‘Unit Gain’ plan. The policy commenced on
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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
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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 and 140: Head Notes: Life assured availed a
Page 141: in English, which suggest that he i
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
Page 191 and 192: 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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