Death Claim - Gbic.co.in

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In the self-contained note, the insurance company stated that the DLA was abusinessman, who took a policy for sum assured of Rs. 50,000/- with DOC 11.11.2003.After a lapse of about 2 years 3 months, the insured died of cancer at his residence.The insurance company further stated they have evidence before them in the form oftreatment papers given by Acharya Harihara Regional Cancer Centre, Cuttack,according to which the DLA suffered from cancer in the cheek and had undergoneradiotherapy (15 sittings) from 04.07.03, but the insured did not disclose these facts inthe proposal form as could be observed from the answers given to question nos. 11(a),11(b), 11(c), 11(d), 11(e) and 11(i). LICI, therefore, stated that the DLA suppressedmaterial information while submitting the proposal form. Since the contract between theLICI and the insured was of utmost good faith and as there was no full disclosure, theinsurance company treated it as misrepresentation made by the DLA and repudiatedthe claim.Decision :On going through the evidence submitted by the complainant, it could be seen that thedeceased had undergone radiotherapy between 04.07.05 to 27.07.05, obviously thedoctor attending on the deceased has corrected the discharge certificate from 04.07.03to 04.07.05. We do not know whether this had been taken into consideration by theinsurance company before deciding on the repudiation. The complainant vehementlyclaimed that the cancer was detected only after 27.05.05 and that the patient wasdischarged originally on 06.06.05 and that he took radiotherapy from 04.07.05 to27.07.05 and, therefore, the disease could not have existed prior to signing theproposal form.As there was contradictory evidence with regard to the period of radiotherapy, it wouldbe fair if the insurance company gets the discharge certificate and other hospitaldocuments verified and then decide about the repudiation of the claim. Accordingly, theinsurance company were directed to review the repudiation by instituting aninvestigation into the claim of the complainant that there has been a mistake inmentioning the duration of radiotherapy and decide the claim on merit.Kolkata Ombudsman CentreCase No. : 674/24/003/L/01/05-06Smt. Purnima JanaVsTata AIG Life Insurance Company Ltd.Award Dated : 13.02.07Facts & Submissions :This petition was filed by the complainant Smt. Purnima Jana against repudiation ofdeath claim by Tata AIG Life Insurance Company Ltd.Shri Supriya Jana, deceased life assured (DLA), purchased an insurance policy withIssue Date 29.11.2003 from Tata AIG Life Insurance Company Ltd. He expired on10.04.2004, the duration of policy being 4 months 11 days. The complainant Smt.Purnima Jana, wife and nominee of the DLA, filed a death claim, but the insurancecompany repudiated the same as there was misrepresentation and non-disclosure offacts in the proposal form. Being aggrieved, the complainant filed this petition andstated that repudiation on the ground of chronic alcoholism could not be the reason forrepudiating the claim for misrepresentation of facts in the proposal form.
The insurance company in their self-contained note stated that they have irrefutableevidence before them for repudiating the death claim of the complainant. The DLA hada CT Scan Report dated 03.11.1999 and the report stated that he was having difficultyin writing. They also submitted proof of discharge certificate, which stated that thepatient was chronic alcoholic and was treated for convulsion and alcoholism. As thesefacts were not brought on record at the time of proposal, the insurance companycontended that the proposer did not submit correct details and, therefore, they treatedit as misrepresentation and repudiated the claim.HEARING :A hearing was fixed where representatives of the insurance company and thecomplainant attended. During the hearing, the complainant stated that her husbandwas not alcoholic and, therefore, the reason for repudiation was not correct.On the other hand, the representative of the insurance company stated that they havefurther evidence in the form of a statement given by the mother of the DLA, whichclearly stated that her son was alcoholic. The DLA also submitted application for leaveon medical ground for treatment to his employer (alcoholism reported in medicalprescription and DLA’s employer cautioned him for delinquent behaviour). The dateswherein he had treatment with regard to alcoholism and convulsion, CT Scan etc. fallbefore the inception of the policy. The representative of the insurance company,therefore, stated that there was misrepresentation in the proposal form as the insuredhad declared that he was fit at the time of taking the policy and hence, the repudiationdecision was correct.Decision :From the above evidence, it was clear that the insurance company investigated theearly death claim thoroughly and found that the insured was alcoholic and wasregularly taking leave for medical treatment and that he was in the knowledge ofhospitalization and his own disease, which were not disclosed in the proposal form.The arguments given by the complainant were not tenable. We, therefore, had noalternative but to agree with the insurance company and confirmed the repudiationmade by them with regard to death claim. The order was passed without any relief tothe complainant.Kolkata Ombudsman CentreCase No. : 616/24/001/L/11/06-07Sk. Rabial HossainVsLife Insurance Corporation of IndiaAward Dated : 14.02.2007Facts & Submissions :This was a petition filed by the complainant SK Rabial Hossain for delay in settlementof death claim by LICI.SK Rabial Hossain was the nominee of the deceased life assured (DLA) SK Jehangir.SK Jehangir died in a road accident on 10.01.2006 at Asansol. The nominee lodged aclaim on 16.08.06 with all relevant documents. The complainant further stated that theDOC as per First Premium Receipt (FPR) was 27.12.04 and the DOC as per renewalreceipt was 28.11.04. According to him, if the DOC is shifted to 27.12.04, the claimwould have been admissible. In spite of written reminders, the claim was not settled.Hence this petition for relief.
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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
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3 months and 14 days of taking poli
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09.06.2003 and the proposal was sub
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Leukemia. Bone Marrow Report dated
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Thus, he withheld facts and was gui
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questions provided in item no.11 of
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the claims excepting the present on
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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 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
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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
Page 209 and 210: asis of which proposal was complete
Page 211 and 212: Consultation/Treatment as proof of
Page 213 and 214: Smt Shantona Kanaiya Ghosh had take
Page 215 and 216: ody with altered behavior for few m
Page 217 and 218: Mumbai Ombudsman CentreCase No. : L
Page 219 and 220: Diabetes Mellitus since 20 years an
Page 221 and 222: 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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