Death Claim - Gbic.co.in

Award Dated : 28.02.2007Head Notes: Death claim under a unit Linked policy. Evidence produced by the insurerproved that the LA was under treatment for hypertension prior to the issue of thepolicy. Complaint was allowed on ex gratia basis to an extent of refund of theinvestment portionFacts of the case and Decision :(Late) Varasala Bhimayya, aged 56 years at the time of proposal, obtained policyno.1854778 for a sum assured of Rs.75,000 from the insurer under a Unit Regularpolicy. The policy was issued under a non-medical plan and it commenced on19.10.2005 with an annual premium of Rs.15,000. The LA died on 11.7.2006 i.e. within9 months from the commencement of the policy and the insurer rejected the claim videtheir letter dated 22.11.2006 on the plea that the LA was suffering from hypertensionfor three years before the issue of the policy.Before death, the LA fell from a staircase on 28.6.2006 and fractured his left hip. Hewas advised complete bed rest and on 11.7.2006 he died of heart attack. The LA wastreated by Dr. R.Ramakrishnam Raju during the terminal illness and he was the familyphysician of the LA. The doctor knew the LA for about ten years and as per the doctor,the LA was suffering from hypertension for about three years and was prescribed Aten-50. He was under the treatment of Dr. Krishnam Raju as an outpatient. The insureralso obtained a questionnaire completed by a family member of the LA, who haddeclared that the LA was using medicines for hypertension for about one year. As theinsurer has established suppression of material information, the complaint was found tobe not entertained. However, as the policy has a provision for savings, the insurer wasordered to refund such investment portion on ex gratia basis.Hyderabad Ombudsman CentreCase No.L-21-002-0354-2006-07Sri B.S.SivaramakrishnaVsSBI Life Insurance Co. Ltd.Award Dated : 12.03.2007Head Notes: Life assured obtained a housing loan from State bank of Mysore andbecame a member of group ‘Super Suraksha Plan’ of SBI Life for coverage ofoutstanding loan. Death claim repudiated on the plea that the LA was suffering fromcritical illness prior to joining the scheme. Insurer could not prove convincingly aboutexistence of disease prior to membership. Hence complaint was admitted.Facts of the case and Decision :(Late) S.B.Beleri, aged 53 years, occupation- Security Guard in State Bank of Mysore,Bhadravathi, became a member of the group ‘Super Suraksha Plan’ of SBI effectivefrom 5.11.2003. The LA submitted an application cum Good Health Declaration of evendate to join the plan. The group policy is meant for borrowers of housing loan from SBIand its associate banks. The LA secured a housing loan from SBI, Shimoga branch andto get insurance coverage on the outstanding loan, he became a member of the supersuraksha plan.The LA died on 15.9.2005 due to HIV. The death claim payment was rejected by theinsurer on the plea that the LA was a HIV patient even before becoming a member ofthe scheme.A personal hearing was held at Bangalore on 14.2.2007. The insurer contended thatthe insurer was infected with HIV about two years before his death and produced a