Death Claim - Gbic.co.in

The insurance company in their self-contained note stated that the death occurredwithin 1 month 4 days from the DOC and the repudiation was done on the ground of“Suppression of material facts”, which they found out from the investigation and writtenstatement of the complainant and her son.Since there were doubts about the evidence available and the reasons for repudiationof the claim, a hearing was fixed. The complainant attended on the day of hearingwhile no person representing the insurance company attended on that day. There wasno letter seeking adjournment from the insurance company. This office proceeded withthe hearing to find out exactly what happened before the death of the deceased.HEARING :On filing the claim papers, the insurance authorities initiated the investigation of theclaim, as it was only 1 month 4 days old. They obtained 3 statements of the familymembers – Smt. Rajkumari Devi (wife), Shri Dileep Kumar (Son) and Shri RamawatarSah (Elder Brother) of the deceased. All of them mentioned treatment of ProstrateGland of the DLA 2 years before by a Homeopath Doctor from Muzaffarpur and thesame was fully cured. According to the insurance authorities, all the 3 statements werewritten and certified to having been read over, explained and admitted by thedeclarant, by one Shri K.Chakraborty, Investigating Officer. The wife and the brothersigned it in Hindi and the son signed in English.During the course of hearing, when questioned about these documents, thecomplainant i.e., wife of the DLA stated that the investigating officer took some signedblank papers from them and recorded what was mentioned in this certificate. Accordingto her, they did not know that the certificate contained the mention of the treatment ofone Prostate Gland by Dr. Ramji Dubey. Further, the investigating officer stated thatthe area was backward; there was poor accessibility to the village and there wasprevalence of Diarrhoea, heart attack and fever in the area. They also mentioned thatthe DLA was a respected person with no bad habits, having perfectly normal healthcondition. The DLA was treated by Dr. S.K.Sinha and died in the doctor’s chamber. Thereport of the investigating team also mentioned about one certificate dated 29.05.05 ofDr. R. Dubey of Muzaffarpur that he did not remember any previous history oftreatment of the DLA in absence of any old prescription. They also recommended therelease of the policy claim to the claimant.Although the Homeopath Doctor Dr. R.Dubey was named in the investigation report andstatement of family members, no certificate or prescription from him was furnishedeither by the insurer or by the complainant. When the complainant was asked about theprescription, she stated that few years before the death, her husband took a neighbourwith him to the Doctor and actually the neighbour was suffering from Prostrate Glandproblem, which was cured by that doctor. It is natural that the DLA does not have anyprescription from the doctor.It was also found from the record that the insurance company not being satisfied by theinvestigation report, got another enquiry conducted by Snippers India Ltd., whonegated the earlier report. However, they stated that the DLA had no moral hazards butmight have suffered from some old disease, hidden from his family members andneighbours. However, there was no documentary proof to substantiate it. It was alsofound that the insurer advised the proposer to undergo some tests viz., CBC, ESR,FBS, Cholesterol, HIV, Tele & ECG, but this office has not been furnished with anymedical test results, which was conducted before accepting the proposal. In theabsence of any representation from the insurance company, this office was unable tocome to a conclusion whether there was any adverse report from the medical tests.Decision :