Death Claim - Gbic.co.in

taken under ‘Flexi Cash flow’ plan for a sum assured of Rs.1,50,000 with thecommencement date of 12.3.2003. The second policy no.460316 was taken under‘Classic Life’ plan for a sum assured of Rs.5 lakhs and it commenced on 8.9.2005.Policy no.75954 covered three types of riders namely (i) Accidental death &dismemberment rider (ii) Critical illness rider (iii) Term rider. These riders are inaddition to the basic life coverage.The LA died on 24.1.2006 due to cardio pulmonary arrest, after a prolonged illness.The insurer settled claim for basic sum assured under policy no. 75954 and rejectedCritical Illness benefit. They also rejected total claim under the second policy, allegingthat the LA did not disclose material information about his state of health whileproposing for the policy. The C.I. benefit under Pol. No.75954 was rejected stating thatthe LA did not suffer from ‘Stroke’, coming within the meaning of the term defined inthe policy conditions.A personal hearing session was held on 13.12.2006, in which both sides participated.The insurer contended that C.I. benefit under the first policy could not be paid, as theLA did not suffer any paralytic stroke. The LA had his first spell of hospitalization forhis terminal illness on 16.9.2005.With regard to the other policy, the LA submitted his proposal on 28.6.2005. As thecase sheet of hospital revealed that the LA was having a history of chronic alcoholism,the insurer rejected the claim stating that the LA did not disclose his personal historyof alcoholism. This point was refuted by the complainant, stating that her husband haddisclosed about his habit of taking drinks. She also contended that the second policywas issued after a medical examination by a doctor designated by the insurer.After a careful examination of the evidences placed on record, it was decided to orderfor payment of claim under the second policy for Rs.5 lakh sum assured. It was alsodecided to uphold the decision of the insurer regarding payment of C.I. benefit underthe first policy.Hyderabad Ombudsman CentreCase No.L-21-001-0423-2006-07Smt.RatnasreeVsLife Insurance Corporation of IndiaAward Dated : 22.02.2007Facts of the case and Decision:(Late) N. Srinivas obtained a policy bearing no.663085363 for Rs.50,000 from Raichurbranch of LIC. The policy commenced on 26.2.2003 under plan 91 for 21 years. The LAdied in a road accident on 22.7.2004. As per police records and Post Mortem report,the LA was under the influence of alcohol at the time of accident.Based on the claim papers received, the insurer settled the claim for basic sumassured of Rs.50000 and rejected double accident benefit stating that the benefit is notpayable as per exclusion clause provided under Cl. 10(b)(i). The present complaint isagainst the decision of LIC not to pay accident benefit amount. The insurer quoted thejudgment given by NCDRC, Delhi under FA No.368/2004 as a case law, whereunder itwas held by the Hon’ble Forum that the construction of the particular word“intoxication” and its meaning are to be read within the terms and conditions of thepolicy.The complainant, who is the Nominee under the policy, contended that her husbandwas not drunk at the time of accident and that the Police filed the FIR at the behest of