Death Claim - Gbic.co.in

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In the self-contained note the insurance company stated that the proposer signed theproposal form on 27.12.2004 and opted for back dating of the risk to 28.11.2004.Originally the proposal was accepted as risk date 27.12.2004 and after the proposersent a letter dated 18.01.05, the risk date was corrected from 27.12.04 to 28.11.04.The life assured died on 10.01.06 as per the death certificate submitted by theclaimant. As per the policy condition, the premiums are payable half yearly and thepremium has been paid up to 28.05.05 and, therefore, the policy was running with thecover up to 28.11.05. Had the DLA paid the premium before 27.12.05 for the next Halfyearlyperiod, the date of death would have fallen during the course of cover of thepolicy. Since the premium for hly. due in November’05 was not paid, according toinsurance company, only grace period was available, which was over by 27.12.05.Since the death occurred after that date i.e., on 10.01.06, the question of paying thedeath benefit did not arise.Decision :On going through the evidence available on record, it could be seen that the proposalwas dated 27.12.04 and the proposer opted for DOC of risk to be from 28.11.04, asback dating was permitted under the LICI Rules. However, inadvertently, the insurancecompany gave the date of risk from 27.12.04. The proposer did not keep quite butrequested LICI to change the DOC of risk from 27.12.04 to 28.11.04, which was dulycomplied by the LICI on 18.01.2005. The life assured paid hly. premium due on28.05.05 on 08.10.2005 and thereby the life cover was operative up to 28.11.05. Therewas no evidence to show that premium due 28.11.05 has been paid. Therefore, thegrace period comes into operation. Had he paid the premium before 27.12.05, thepolicy would have been in-force at the time of death of the life assured on 10.01.06.Now, coming to the argument of the complainant that the risk date should be taken as27.12.04, as was inadvertently done by the LICI, could not be accepted as it had beencorrected at the volition of the insured by his letter. Therefore, the grace period wouldstart only from 28.11.05 and not from 27.12.05. Under these circumstances, we wereunable to agree with the arguments of the complainant and accordingly, the petitionwas disposed without any relief to the complainant.Kolkata Ombudsman CentreCase No. : 423/21/001/L/09/06-07Shri Pradip Ranjan DeyVsLife Insurance Corporation of IndiaAward Dated : 20.02.07Facts & Submissions:This was a petition filed by Shri Pradip Ranjan Dey on repudiation of death claim byLICI.Smt. Smriti Dey, deceased life assured (DLA), a 36 year old self-employed lady,purchased a LICI policy for Rs. 1 lakh with DOC 23.04.03, date of proposal being30.06.03 and she expired on 24.01.04. Cause of death being CRF due to ruptureduterus in a case of terminated pregnancy.Shri Pradip Ranjan Dey, husband and nominee of the DLA, submitted claim forms toLICI, but the claim was repudiated due to suppression of fact of pregnancy whilesubmitting the proposal form. The claimant represented before the insuranceauthorities, but they confirmed the repudiation as the question no. 13(A) was notcorrectly answered. According to the complainant, his wife was not pregnant at the
time of taking the policy and that the medical report at the time of taking the policyincluded urine test. According to him, a person who had two successful deliverieswould not take an insurance cover with advance knowledge of pregnancy and that shewould die during the pregnancy. He relied on the decision of Hon’ble Supreme Court inthe case of Surender Singh and State of Punjab, in which it was stated “It may berecalled that this Court repeatedly observed that suspicion, however, grave cannot takethe place of legal proof”. In another case, the Apex Court observed “there isrequirement of proof and such requirement cannot be substituted by surmise andconjecture”. Further, the complainant furnished a certificate from Dr. A.K.Majhi dated08.06.06, which is reproduced below:“Bleeding may occur for early pregnancy cyclically or irregularly due to various reasons…. It may or may not be a serious complication and the patient may be confused toascertain it to be menstruation. As such she (DLA) might have confused of her earlypregnancy due to bleeding occurring on 24.06.03”(before submission of proposal)The insurance company in their self-contained note stated that the repudiation wasmade because of the delivery and ultimate death that took place, which indicated thatshe was pregnant nine months from that date, which fell before the date of proposal. Inthe proposal form, she mentioned that her menstruation cycle was on 24.06.03, whichaccording to them, was not correct and, therefore, question no. 13(A) was not correctlyanswered and it became suppression of material facts. Hence, repudiation took place.HEARING:A hearing was fixed. The complainant Shri Pradip Ranjan Dey could not attend due tounavoidable circumstances. However, the representatives of the insurance companyattended. They stated that they have irrefutable proof that Smt. Smriti Dey waspregnant before the inception of the policy. They gave a copy of the prescription dated01.08.03 given by Dr. A.K.Maji, in which he stated that Last Menstruation Period (LMP)was 24.04.03 while expected Date of Delivery (EDD) was 30.01.04. Similarly, there wasanother prescription dated 12.11.03 from the same doctor, in which it was mentionedthat the EDD was 30.01.04. According to the insurance authorities, this clearlyindicated that she was pregnant before signing of the proposal form.Decision:We proposed to dispose of the petition ex-parte on merits, as the complainant couldnot attend. On going through the evidence submitted by the insurance authorities, itwas clear that the very same doctor, who gave a certificate dated 08.06.06 (mentionedabove in para 3) had clearly written that the LMP was 24.04.03 and the EDD was30.01.04. This prescription given by him irrefutably proved that the deceased lady waspregnant before signing the proposal form and she had not mentioned the answer toquestion no. 13(A) correctly. This clearly showed that there was misrepresentation andsuppression of material facts. Since the policy is a contract of utmost good faith, wehad to agree with the repudiation made by the insurance company. Accordingly, theclaim was disposed of without any relief to the complainant.Kolkata Ombudsman CentreCase No. : 678/24/001/L/01/05-06Smt. Bharati KumariVsLife Insurance Corporation of IndiaAward Dated : 06.03.07Facts & Submissions:
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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
Page 12 and 13:
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
Page 24 and 25:
adhikar ewam Rin pustika ” for Ag
Page 26 and 27:
10 days from date of commencement a
Page 28 and 29:
grounds of suppression of material
Page 30 and 31:
the claim for the reason “Suppres
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It is observed from the Medical cer
Page 34 and 35:
It has also not been verified by th
Page 36 and 37:
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
Page 105 and 106:
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
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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
Page 171 and 172: evidence to prove that the DLA was
Page 173: The insurance company in their self
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
Page 223 and 224: into consideration, it would be rea
Page 225:
Mumbai Ombudsman CentreCase No. : L
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