Death Claim - Gbic.co.in

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Life Insurance Corporation of IndiaAward Dated : 11.12.2006Shri Shivaji Vishnu Pol had taken a Life Insurance policy bearing no. 907499727 fromLife Insurance Corporation of India, Branch 927 through proposal dated 30.07.2003 forSum Assured of Rs.75,000/ under Plan and Term (14-15). The commencement of thepolicy was 20.08.2003. Shri Shivaji V Pol expired on 29.12.2004. When Smt Rupali SPol wife and nominee under the policy, preferred a claim under the above said policy toLife Insurance Corporation of India, S.S.S Divisional Office of LIC repudiated the claimstating that the deceased life assured had withheld material information regarding hishealth at the time of effecting the assurance and in the proposal form dated 30.7.2003They said they had indisputable proof to show that the Life Assured was suffering fromJuvenile diabetes since age 12-13 years and was on insulin. He was also a case ofchronic pancreatitis. These facts were not disclosed at the time of taking the policy.Hence based on this LIC repudiated the claim. Not satisfied by the said decision, SmtRupali S Pol approached this Forum for redressal of her grievance. After perusal of therecords parties to the dispute were called for hearing. The relevant records pertainingto the case have been perused.It is evident from the history recorded in the casepapers of KEM hospital and Jaslok hospital that Shri Shivaji Pol was javelin diabeticsince age 12/13 years.It can be established that the above facts were not disclosed inhis proposal dated 30 th July, 2003. The analysis of the records leads to the conclusionthat the deceased life assured had fraudulently suppressed material information in hisproposal form; instead, he gave deliberate incorrect statements. Since he was takinginsulin for diabetes, he was very much aware of it. The cause of death, viz.,“Carcinoma, Head of Pancreas”, has a direct nexus with the suppressed materialinformation. “Chronic Pancreatitis may lead to pancreatic failure causing malabsorptionand diabetes mellitus. The pancreas often becomes calcified producing visibleshadowing on X rays”. The above is extracted from the Oxford’s Concise MedicalDictionary, Indian Edition. Had Shri Pol disclosed the correct information about hispast/present history of illness as also the treatment being taken by him, to the Insurerat the proposal stage, the Life Insurance Corporation of India would have called forvarious special reports before underwriting the proposal and taken appropriate decisionin acceptance of the proposal.In the circumstances, this Forum has no justifiable reason to interfere with the decisionof LIC of India to repudiate the claim on the ground of non-disclosure of materialinformation.Mumbai Ombudsman CentreCase No. : LI-232 of 2006-2007Smt JayalaxmiV/s.Tata AIG Life Insurance Company Ltd.Award Dated : 28.12.2006Shri Alva Ramayya Santha had taken a Term Assurance Policy for 20 years with returnof premium plan under policy No.C001840670 from Tata AIG Life Insurance Companylimited for a Sum Assured of Rs. 2,00,000/-. The policy also covered an additionalAccidental death benefit of Rs. 2,00,000/-, The date of proposal for insurance was26.10.2005. Shri Alva Ramayya Santha unfortunately expired on 18.1.2006 due toTerminal Cardiac Arrest in a case of Orbital Mucor-mycosis with Diabetes Mellitus withstroke. When Smt Jayalaxmi preferred a claim under the said policy, the Companyrepudiated the claim stating that Shri Ramayya Santha Alva was on insulin therapy for
Diabetes Mellitus since 20 years and this was not disclosed at the time of taking thepolicy. Not satisfied with the decision of the Company Smt Jayalaxmi approached theOffice of the Insurance Ombudsman. After perusal of the records parties to the disputewere called for hearing. It is evident from the history recorded by the doctor at the timeof admission to KEM Hospital that the deceased life assured was suffering fromdiabetes for a long time and was on Insulin. The case papers of Holy Family Hospitalalso reveals that he was a known case of IHD, DM, HTN, ARF and the diagnosisarrived at Holy Spirit Hospital was uncontrolled diabetes mellitus and acute renalfailure and was advised dialysis urgently. The analysis of the medical records leads tothe conclusion that the Diabetes Mellitus which the deceased life assured was sufferingmust have contributed for worsening of the condition of the life assured and it was inexistence before making the application for insurance. The duration of D.M. can bedebated as other than hospital record no evidence was produced but certainly thepresent stage can’t develop in two months, the history certainly goes back prior to thisperiod and since he was taking insulin for D.M. so it was also known to him. As suchthe contention of the complaint that the deceased was not suffering from DiabetesMellitus is not sustainable.In the circumstances, this forum finds no valid reason to interfere with the decision ofTATA AIG Life Insurance Co. to repudiate the claim for the sum assured under thepolicy.Mumbai Ombudsman CentreCase No. : LI-171 of 2006-2007Smt Jayamala RaiV/s.Life Insurance Corporation of IndiaAward Dated : 31.01.2007Shri Rakesh Raman Rai had proposed for three Life Insurance policies under JeevanMitra Triple cover for terms 16,19,21 respectively from Life Insurance Corporation ofIndia, Branch 934 of Thane Divisional Office through proposals dated 11.03.2005 forSum Assured of Rs.2,00,000/- each. Unfortunately, Shri Rakesh Raman Rai was shoton 10.5.2005 at around 11.30 p.m. and died at midnight. When Smt Jayamala Rai , wifeand nominee under the policy preferred a claim to Life Insurance Corporation of India,Kalyan Branch Office of Thane D.O. sent cheques for Rs. 2,00,000 each under eachpolicy stating that LIC decided to settle the claim on ex-gratia basis as the contractwas unconcluded. Not satisfied with this decision, she represented to the Zonal Officeand not receiving any favourable response from them approached this Forum forredressal of her grievance. After perusal of all the records submitted to this Forumparties to the dispute were called for hearing Both documentary and oral evidencesadduced at this Forum have been examined.The complainant submitted copies of theFPR dated 11.5.05 and LIC has also submitted copy of First Premium adjustment sheetdated 11.5.05 and proposal/Review Rating Sheet of the proposals. The point to beexamined in this case is whether there was a concluded contract before the death ofthe Life Assured. In this case, the proposer had submitted all the requirementsincluding deposit towards first premium. He had disclosed all the previous policyparticulars including the lapsed policies. The proposer had informed by his letter dated31 st March/10 th April, 2005 that he was not interested in reviving 3 of his lapsedpolicies. As revival of the lapsed policies was a pre-condition for acceptance of thefresh proposals the Insurer decided to drop the proposals and the decision of LIC wasconveyed to the Proposer. This amounts to a counter proposal by LIC. Though LIC
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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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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 173 and 174: The insurance company in their self
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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 and 216: ody with altered behavior for few m
Page 217: Mumbai Ombudsman CentreCase No. : L
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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