Death Claim - Gbic.co.in

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assured had suppressed two spells of medical history and hospitalisation forMyasthenia Gravis in 1999 and 2001. Even in such circumstances, considering the factthat the policy had run for nearly 2 ½ years, the insurer had paid the basic sumassured plus vested bonus on EX-GRATIA which the claimant had accepted in full andfinal settlement of all claims. The accident benefit was not payable as per the policyissued and, besides, the ex-gratia payment itself extinguished any further claim on thepolicy. In the circumstances, the complaint was found to be devoid of merits and thesame was dismissed.Kochi Ombudsman CentreCase No. : IO/KCH/LI/21-001-117/2006-07Smt.Dolly KuriakoseVsLife Insurance Corporation of IndiaAward Dated : 12.12.2006The complaint under Rule No.12(1)(b) read with Rule 13 of the RPG Rules, 1998relates to repudiation of a life insurance claim under Policy No. 773502618 held by thehusband of the complainant. The policy had commenced on 28.6.2000 and the samewas revived twice on 30.4.2003 and 26.7.2004 on the basis of declarations of goodhealth at the relevant points of time. All the same consequent on the death of the lifeassured on 28.3.2005, the investigations revealed that the life assured was sufferingfrom brain tumor right from April 2003 during which period of time, the first revival waseffected. From 27.4.2003 to 30.4.2003, the life assured was an inpatient at the JubileeMission Hospital, Trichur and the C.T.Scan done on 29.4.2003 had diagnosed theproblem as “low grade glioma in right frontal region”. In these circumstances, the claimwas repudiated for suppression of material facts at the time of revival. There was nopaid up value accrued on the policy as on the date of revival and therefore nothing waspayable to the complainant. In the circumstances of the case, the decision of theinsurer to repudiate the claim was found to be on solid grounds and hence the samewas upheld duly dismissing the complaint.Kochi Ombudsman CentreCase No. : IO/KCH/LI/21-001-180/2006-07Smt.Ramla BeeviVsLife Insurance Corporation of IndiaAward Dated : 12.12.2006The complaint under Rule 12(1)(b) read with Rule 13 of the RPG Rules, 1998 relates torepudiation of a life insurance claim under Pol.No.781485988 held by the husband ofthe complainant. The policy had commenced on 10.6.98 and it was revived on19.10.2005 by paying 7 quarterly premia cumulatively. The revival was supported by aMedical report and a personal statement of health. The life assured died on 30.10.2005and from the investigations and reports received from Medical College,Thiruvananthapuram, it was revealed that the life assured was suffering fromHypertension and Diabetes since 1 year and chronic kidney disease for 1 ½ months.Haemodialysis was also done on 15.10.2005. All these facts were not mentioned in thepersonal statement of health, which, as per the complainant was written out by theagent. The insurer had initiated action against the agent as well as the MedicalExaminer. However, although the life assured also should have been careful aboutwhatever was written out in the statement of health, as a lowly educated man, he could
not be blamed entirely. But, the misrepresentation of facts being of a very seriousnature, the revival repudiation alone by the insurer was upheld even while the insurerwas asked to reimburse 50% of the revival arrears paid on 19.10.2005 as ex-gratia, onhumanitarian grounds.Kochi Ombudsman CentreCase No. : IO/KCH/LI/21-001-219/2006-07Shri.K.BabuVs.Life Insurance Corporation of IndiaAward Dated : 31.1.2007The complaint under Rule 12(1)(b) read with Rule 13 of the RPG Rules, 1998 relates torevival repudiation of a life insurance claim under Pol.No.781785808 held by lateSmt.R.Bindu, wife of the complainant. The policy under Table & Term 125-20 hadcommenced from 9.7.99, but lapsed from April 2002 onwards. It was revived on28.6.2004 on the basis of a DGH which declared the life assured hale and hearty.However, the medical records obtained by the insured proved that the life assured wasa patient of tuberculosis meningitis right from 9.10.2003. She had inpatient treatmentsat ESI Hospital and the Medical College, Trivandrum. These details having been foundconcealed in the personal statement submitted for revival of the policy on 28.6.2004,the claim was repudiated by the insurer. However, on a closer scrutiny of the records,it was doubtful whether the life assured or her husband was really aware of the serioushealth problems of the life assured as they were very lowly educated and struggling fortheir livelihood. While the stand of the insurer in repudiating the claim was fullyjustified, as there were misrepresentations in the DGH, considering the pitiablecircumstances of the complainant and possible unintentional misrepresentations in theDGH, a small ex-gratia of Rs.3000/- was allowed even as the repudiation was upheld.Kochi Ombudsman CentreCase No. : IO/KCH/LI/21-002-186/2006-07Smt.Sujatha UdayanVs.SBI Life Insurance Co.Ltd.Award Dated : 31.1.2007The complaint under Rule 12(1)(b) read with Rule 13 of the RPG Rules, 1998 arose outof repudiation of a claim by the insurer under a Group Insurance policy coveringoutstanding housing loans of SBI Group customers. The complainant’s husband hadraised a loan from SBT, Kodannur and thus joined the above scheme based on a DGHwherein the life assured was declared healthy in all respects. When a claim arose, theinsurer had caused an investigation and found that the life assured was suffering fromcertain health problems which were not mentioned in the said DGH. The life assrueddied on 16.6.2005 due to Cirrhosis of liver, Hepatic encephalopathy etc. within a periodof 8 months and a few days after joining the scheme. The investigations by the insurerreportedly revealed that the life assured was suffering from Diabetes for the past sixyears. The medical certificate from AIMS Kochi stated that he was under treatmentfrom Nov.2003. However, the complainant maintained that although treatment forDiabetes was being taken for 2-3 years, conditions like Cirrhosis of liver and Hepaticencephalopathy were diagnosed only on admission into the hospital. Other than avague statement by the medical attendant and the Investigator, the insurer had notproduced any evidence to support their argument relating to concealment of a critical
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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
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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
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He had concealed the material fact
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They further needed claim forms No.
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on life of her husband Late Shri. R
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Delhi Ombudsman CentreCase No. : LI
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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 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: The complaint under Rule 12(1)(b) r
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
Page 199 and 200: 31.03.05/11.04.05 issued under the
Page 201 and 202: Shri Sarvjit Gupta had lodged a com
Page 203 and 204: complainant awarded payment of full
Page 205 and 206: with him during the period 02.03.04
Page 207 and 208: 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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