Death Claim - Gbic.co.in

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Head Notes: Life assured had two policies on his life and died within a short periodfrom the commencement dates of the policies. LIC repudiated the claims on the pleathat the LA did not disclose his personal medical history correctly. Evidence submittedby LIC was found to be in order and hence the complaint was dismissed.Facts of the case:(Late) Laxman Venkatesh Raghunathi, Agricultural Assistant in the office of the Asst.Director of Agriculture, Sirsi obtained policies bearing nos. 632187163 for Rs.50000and policy no.638815586 for Rs.30000 from Sirsi branch of LIC with commencementdates of 25.3.2003 and 20.3.2004 respectively. The policies were issued under Plan14-20; 14-15 respectively and under SSS scheme. The LA died on 15.11.2004. As theclaims were treated as early claims, LIC investigated the claims and repudiated thesame as they came to know that the LA was under treatment even beforecommencement of the policies. As per evidence collected by LIC, the LA was admittedinto Rotary Charitable Hospital, Sirsi on 3.10.2002 with complaints of abdominal pain,viral hepatitis and was discharged on 5.10.2002. Further, the enquiries of LIC revealedthat the LA was a chronic alcoholic and death was due to alcoholic cirrhosis. As the lifeassured did not disclose about his hospitalization in 10/2002 for viral hepatitis, LICrepudiated the claim vide letter dated 9.3.2005.Section 45 of the Insurance Act, 1938 isnot applicable.Decision : LIC settled death claims under some more policies which were held by theLA, which come under non-early category. As per the complainant, the LA sufferedfrom illness for about a month before death, while the insurer contended that the LAwas suffering from hepatitis since 3.10.2002. They have also pleaded that there is anexus between the final cause of death and the disease for which the LA washospitalized in 10/2002. As the evidence produced by LIC was found to be in order, thecomplaint was dismissed for reasons of non-disclosure of material information.Hyderabad Ombudsman CentreCase No.L-21-001-0392-2006-07Smt. Renuka BarkiVsLife Insurance Corporation of IndiaAward Dated : 26.02.2007Head Notes: Early death claim on a policy for Rs.30000 sum assured. Death occurreddue to suicide and the LA had a proven past medical history of mental illness. Claimwas rejected by LA for reasons of suppression of past medical history. Based on theevidence produced by LIC, the complaint was dismissed without any relief.FACTS OF THE CASE AND DECISION :Late Laxman Barki, the LA under policy no.637188463 submitted a proposal for thepolicy to Haveri branch of LIC on 8.8.2003. He nominated his sister Smt. Renuka underSec.39 of the Insurance Act, 1938. The LA allegedly committed suicide on 23.11.2004by falling under a running train and as per police records, it was held to be a case ofsuicide due to mental illness. As the LA died in about one year-three months periodfrom the commencement date of the policy, LIC investigated the claim. As per formssecured by LIC, the LA was treated in Manasa Nursing Home at Shimoga from14.10.1995 to 20.10.1995 for mental disorder. The cause of death also was attributedto mental disorder by the complainant in her claim forms given to LIC. The LA wastreated in the Government Mental Hospital, Dharwad from 9.4.2004 to 8.5.2004. As thefinal cause of death is due to mental disorder, the insurer could establish a clear nexusbetween the past medical history and cause of suicide. As the insurer’s repudiation
action was found to be based on proper evidence, it was decided to uphold therepudiation action and accordingly the complaint was dismissed.Hyderabad Ombudsman CentreCase No.L-21-002-0304-2006-07Smt. ChandiniVsSBI Life Insurance Co. Ltd.Award Dated : 28.02.2007Head Notes: Life assured was a borrower of housing loan from SBI and joined a groupinsurance policy of the insurer. Claim was repudiated on the plea that the life assuredwas suffering from a critical illness even prior to joining the policy. The evidenceproduced did not indicate any past medical history and hence the complaint wasadmitted.Facts of the case and Decision :(Late) Sri Ramesh borrowed a loan of Rs.7,50,000 from SBI, Mangalore branch forhouse construction purpose. He joined “Super Suraksha” master policy of SBI Life, bysubmitting a good health declaration form dated 23.11.2004. The group policy is meantfor housing loan borrowers of SBI and its associate banks. As per policy conditions,risk coverage is available for the outstanding loan as per original EMI scheduletogether with outstanding interest. The LA died on 10.3.2006 due to Hepato CellularCarcinoma while taking treatment in City Hospital Research & Diagnostic Centre,Mangalore. The claim was repudiated by the insurer stating that the LA was sufferingfrom liver disease prior to the date of joining the scheme. A personal hearing into thematter was held on 14.2.2007.The insurer produced copies of prescriptions dated 24.11.2004 and a certificate from adoctor named Dr. B.V.Tantry in which it was stated that the LA was suffering fromjaundice and other ailments for about one and half months before. The complainantcontended that her husband was healthy at the time of proposal for insurance. The LAwas working as a Junior Traffic Assistant in New Mangalore Port Trust, Panambur. Shecontended that her husband first consulted a doctor on 8.1.2006. She also contendedthat the investigator appointed by SBI Life misbehaved with her when he came forinvestigating the claim. She claimed that the investigator demanded some money for afavorable report and on her refusal to pay money; the investigator submitted fabricatedmedical report dated 24.11.2004 from Dr. B.V.Tantry and the insurer repudiated herclaim on the basis of that report. She claimed that the investigator of the insurerfabricated some certificates purported to have been issued by Dr. B.V.Tantry to takerevenge against her for her refusal to pay money. It was also held by her that shelodged a police case against the investigator for his alleged misbehavior with her. Itwas her claim that her husband was not treated in the hospital in the year 2004 asmade out by the insurer.After personal hearing session and after examining all the papers produced by theinsurer, it was decided to reject the contention of the insurer. The insurer was orderedto admit the claim as per policy conditions.Hyderabad Ombudsman CentreCase No.L-21-009-0438-2006-07Sri V.Surya NarayaVsBajaj Allianz Life Insurance Co. Ltd.
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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
Page 34 and 35:
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
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In the hearing the complainant stat
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VsLife Insurance Corporation of Ind
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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 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: the owner of the opposite vehicle i
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
Page 193 and 194: dispute the will but contended that
Page 195 and 196: Jaiswal who in their report confirm
Page 197 and 198: 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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