Death Claim - Gbic.co.in

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Thus rejection of death claim by LIC of India for deliberate misstatement andwithholding material information regarding health and habits of the life assured at thetime of proposing for assurance under the above policy is held sustainable. Hence, thisForum finds no justifiable reason to interfere with the decision of LIC of India.Mumbai Ombudsman CentreCase No. : LI-036 of 2006-2007Smt Sangita Manish RuiaV/s.HDFC Standard Life Insurance Company Ltd.Award Dated : 05.12.2006Shri Manish Ruia had taken a HDFC Children’s Double Benefit Plan bearingno.000000344373 from HDFC Standard Life Insurance Company Ltd through proposaldated 23.03.2004 for a Sum Assured of Rs.4,00,000/-Unfortunately Shri Manish Ruiaexpired on 03.01.2006 due to Cardio Respiratory Arrest, primary cause beingGlioblastoma multi forme. When Smt Sangita M Ruia, wife and Appointee under thepolicy, preferred a claim under the above said policy to HDFC Standard Life InsuranceCompany Ltd, they repudiated the claim stating that the deceased life assured hadwithheld the information of the diagnosis of Abdominal Koch’s in February, 2004 andabout the Anti Koch’s treatment he received. Not satisfied by the said decision SmtSangita M Ruia appealed to the Grievance committee for reconsideration of thedecision, however the Company reiterated their stand of repudiation. Aggrieved by thisdecision, Smt Sangita M Ruia approached this Forum seeking intervention of theOmbudsman in the matter of settlement of her claim.After perusal of all the recordssubmitted to this Forum, parties to the dispute were called for hearing. The relevantrecords pertaining to the case have been perused and it is evident from the casepapers that the deceased Life Assured, Shri Ruia, was suffering from AbdominalKoch’s disease since February, 2004. i.e. before the date of policy and that he wastaking Anti koch’s treatment right from February, 2004, was not disclosed by the lifeassured in his proposal dated March 23, 2004. Although the cause of death is“Glioblastoma Multiforme, left temporal”(which means a malignant tumour in the brain),which has no known nexus with abdominal koch’s disease, as contended by theComplainant, yet, had Shri Ruia disclosed the correct information about hispast/present history of illness as also the treatment being taken by him to the Insurerat the proposal stage, HDFC Standard Life Insurance Company would have postponedthe proposal and would have reconsidered issuing the policy only after he wascompletely cured of the said disease after calling for relevant medical reports as pertheir underwriting norms. Smt. Sangita Ruia’s contention that her husband was curedof the abdominal koch’s disease after taking treatment for four months does not holdground as the hospital papers and discharge summary (which was issued in earlyJanuary, 2005) reveal that he was on treatment for the same since ten months. Eventhe prescriptions of Dr. Rohini Choughale submitted by the Complainant subsequentlyproves that the deceased life assured was on treatment for T.B. till 2.3.2005. Asregards the nexus between the cause of death and the illness suffered prior to takingpolicy, the same need not be established as it would be sufficient to prove themateriality of the suppressed information, which actually affected the assessment ofthe risk, by the Insurer. In this case from the above facts and the related documentsproduced by the Respondent it is clear that the deceased life assured was aware of theabdominal Koch’s disease he was suffering and he deliberately did not disclose thefact in the proposal form which was material to assess the risk by the Insurer.
Mumbai Ombudsman CentreCase No. : LI-030 of 2006-2007Smt Yogita Y SingasaneV/s.Life Insurance Corporation of IndiaAward Dated : 07.12.2006Shri Yashwant Maniram Singasane had taken a policy from Life Insurance Corporationof India, Branch 936 of Thane Divisional Office through proposal dated 08.02.2004 fora Sum Assured of Rs.30,000/- by making a single premium payment of Rs.25,765. ShriYashwant Maniram Singasane expired on 11.02.2005 due to Terminal Cardiorespiratory failure due to septicemia in a case of arterial and Venous gangrene in caseof post. op coronary artery by pass graft with cellulites. When Smt Yogita Y Singasane,wife preferred a claim under the above said policy, Life Insurance Corporation of Indiarepudiated the claim stating that the deceased life assured had withheld materialinformation regarding his health at the time of effecting the assurance. Not satisfied bythe said decision Smt Yogita Singasane approached this Forum. After perusal of all therecords submitted to this Forum, parties to the dispute were called for hearing. Therecords pertaining to the case have been analysed. It is apparent from the medicalrecords that Shri Yashwant Singasane had undergone Angiography and CABG on18.9.03 and 23.9.03 respectively and this information which was vital was not disclosedby Shri Singasane at the time of taking the policy. Had he disclosed these facts at thetime of proposal, LIC would have called for relevant special reports and takenappropriate underwriting decision. Hence LIC’s repudiation of the claim on the groundof withholding material information regarding his health is legally justified.However, the complaint of Smt Yogita Singasane has to be examined in the light of thecircular ref: Mktg/CRM/550/23 dated 13.12.2005 issued by Central Office of LIC. As perthis circular, where it is established that if there was no intention of the deceased todeliberately misrepresent/suppress facts, an ex-gratia payment may be considered onthe basis of merit of the case, maximum to the extent of 90% of the single premium. Itis to be noted that after the claim was repudiated by the Divisional Office the claimant,Smt Yogita Singasane had represented her case to the Zonal Claims ReviewCommittee and it appears that the Zonal Claims Review committee in April, 2006before upholding the decision did not take into consideration the said circular.In theinstant case, the sum assured under the policy was Rs. 30,000 and the life assuredhad paid premium of Rs. 25,765. On the face of it, it appears that the life assured tookthe policy for investment purpose rather than risk cover and as such there is no reasonto presume that he deliberately misrepresented or suppressed the facts intentionally.The deceased did not propose for high risk policy or high Sum Assured looking to hishealth conditions. By pass surgery scars are apparently visible on the chest and it wasnot pointed out in the medical report and Agents report. Looking to these facts, denialof Ex-gratia is not justified.The claim of Smt Yogita Y Singasane under policy no.923046312 on the life of late ShriYashwant Maniram Singasane is not tenable. However, in view of delay in consideringex-gratia payment, LIC is directed to pay an ex-gratia payment of 95% of the singlepremium collected by them.Mumbai Ombudsman CentreCase No. : LI-157 of 2006-2007Smt Rupali Shivaji PolV/s.
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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
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LIC that other two policies of Sum
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Branch Office of LICI. It is stated
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We have considered the photocopies
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On the circumstances aforesaid, it
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nos.722662607 for Rs.50000/- and 72
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information. The insurer also suspe
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The claim was rejected by LIC stati
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Facts of the Case: (Late) G.Appa Ra
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Head Notes: Life assured availed a
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in English, which suggest that he i
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LIC about usage of herbal medicines
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age proof. She requested for settle
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the owner of the opposite vehicle i
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action was found to be based on pro
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certificate issued by one Dr.H.R.De
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suffering from disease prior to rev
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establish that the LA failed to dis
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The complaint under Rule 12(1)(b) r
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not be blamed entirely. But, the mi
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hypertensive before the inception o
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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 173 and 174: The insurance company in their self
Page 175 and 176: time of taking the policy and that
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Page 179 and 180: their own guidelines can consider t
Page 181 and 182: the contract was not complete and e
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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: ody with altered behavior for few m
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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