Death Claim - Gbic.co.in

Award Dated : 21.03.2007Facts of the case and Decision:The complainant is the nominee under the policy no. 11552753 for a sum assured ofRs.5 lakhs taken by (late) Kandukuri Dayakar. The policy was ‘Unit Gain’ plan and theLA paid first installment premium of Rs.10,000. Term of the policy was 31 years. TheLA died on 9.12.2005 allegedly due to white jaundice. The claim was rejected by theinsurer vide a letter dated 3.8.2006 alleging that the insured had grossly overstated hisincome in the proposal dated 30.9.2005.The insurer also held in their rejection letterthat the claimant submitted an invalid death certificate containing discrepancies. Apersonal hearing session was held on 27.2.2007 at Hyderabad in which both sideswere represented.The insurer contended that the LA declared an annual income of Rs.150000 in theproposal, while their enquiries revealed that the LA’s income was only Rs. 30000 asper ration card for the year 1998-2003. The insurer also claimed that the widow of theLA was mentioned as the head of the family in the ration card. The insurer furtherclaimed that the complainant could not produce a fresh ration card for the current yearand hence they rejected the claim.The complainant produced a certificate issued by Mandal Revenue Officer (MRO) oftheir town showing an income of Rs.98,000. The complainant also declared that heowns a General Stores and Telephone booth from which they get substantial income.She informed that she declared the sources of income to the MRO to get an incomecertificate. From the insurer’s side there was no record to disprove the certificateissued by the MRO. The complainant further produced a revised death certificateshowing correct date of death. During the personal hearing session the insurer’srepresentative informed that they would have given a sum assured of Rs.5,00,000 foran annual income of about Rs.1 lakh. As the policy was issued to the DLA afterobtaining a Moral hazard Report from the Agent/Sales Team Manager, it was decidedto allow the complaint. The insurer was ordered to settle claim as per policy conditions.Hyderabad Ombudsman CentreCase No.L-21-001-0458-2006-07Smt. V. MadhaviVsLife Insurance Corporation of IndiaAward Dated : 26.03.2007Facts of the case & Decision:(Late) V. Niranjan Reddy obtained policy nos.670686205 and 671466311 from Ongolebranch of LIC. The first policy commenced on 15.3.1993 for Rs.25000 and the secondpolicy on 15.3.1997 for Rs.25000. The policies were revived on 10.12.2004 and20.8.2004 respectively on non-medical basis by submitting DGH. The LA died on31.12.2004 and the claims under both policies were rejected by LIC on grounds ofsuppression of material information at the time of revival. LIC offered to pay paid upvalue under the policies, but the complainant approached this office for admission ofclaims for the full sum assured.The cause of death was cancer of buccal mucosa of rt.cheek with secondaries in liverand brain. The insurer investigated the claim and found out that the LA was undertreatment since 15.10.2003 for ulcer in mouth. LIC collected relevant hospital recordsin support of their repudiation action. As LIC could prove beyond doubt about the LA’s