Death Claim - Gbic.co.in

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same till death claim arises. The Respondent also has not reduced this accidentbenefit premium at the time of converting the policy from without profit to with profitand change of mode of premium installment from quarterly to yearly on 17.04.1997.The Respondent has accepted the accident benefit premium continuously for 8 yearsand refused for the accident benefit claim merely on the ground that accident benefitwas not desires by the DLA in the proposal form.During hearing the Respondent stated that the DLA has not opted for the accidentbenefit in the proposal form at the time of taking the insurance policy. Similarly theDLA has also not asked for the accident benefit at the time of executing the option toalter the policy from without profit to with profit hence the accident benefit claim wasrepudiated. The Respondent further informed that the amount of accident benefitpremium was wrongly included while calculating the normal premium of the policy dueto an oversight which was refunded to the Complainant.It is observed from the records that the premium for accident benefit was beingaccepted by the Respondent since the inception of the policy. They have not taken anynotice regarding adjustment of premiums with the premium of accident benefit duringeight years. Further, it appears that the Respondent has neither refunded the premiumof accident benefit accepted by them nor intimated to the DLA at any stage during thisperiod.It is also observed from the copy of policy bond issued where class of assurance wasmentioned as “ENDOWMENT ASSURANCEPOLICY WITHOUT PROFIT (WITHACCIDENT BENEFIT)” and the premium for accident benefit was also being chargedsince beginning of the policy. There after no care was taken to refund the amount ofaccident benefit or to alter the policy bond or any intimation to the DLA in this behalf.In view of the above, it is clear that there is lapse on the part of the Respondent. Thereis no concrete reason found to deny the payment of accident benefit claim by theRespondent even after acceptances of premiums for the period of 8 years.In view of the above, it stands that the Respondent’s decision of repudiation of theaccident benefit claim payment under the Policy is not tenable.Hence, the Respondent is directed to pay the accident benefit claim amount underPolicy No. 341935832 after deducting the refunded premium of accident benefit within15 days of receipt of this order failing which the Respondent shall be liable to payfurther interest at the rate of 9% per annum from the date of this Order till the date ofactual payment.Bhopal Ombudsman CentreCase No.: LI-1126-21/11-07/INDShri Chandraji GurjarVsLife Insurance Corporation of IndiaAward Dated : 14.02.2007Shri Chandraji Gurjar, Resident of Village: Panchdevra, Tehsil: Manasa, Distt.:Neemuch (M.P.) (hereinafter called Complainant) is the brother of Late Shri BhairolalGurjar, Deceased Life Assured (in short DLA). The DLA had a life insurance policynumbered 344481789 taken from LIC of India, DO: Indore, BO: Neemuch (hereinaftercalled Respondent). The Policy commenced on 28.08.2004 under Jeevan Anand PlanTable/Term: 149-21 for Sum Assured of Rs. 1,00,000/-. The DLA expired on 02.08.2005due to high fever. Thus the Policy had run for 11 months & 5 days. The death claimwas preferred by the Complainant with the Respondent but the same was repudiated on
the grounds of suppression of material facts regarding health of DLA and withoutincome at the time of taking policy. The complainant had referred the case toRespondent’s Claims Review Committee for reconsideration which was also upheld bythem on 01.09.2006. Aggrieved from the repudiation action of Respondent, theComplainant has lodged a complaint with this Office seeking directions to Respondentto settle the claim amount.The complaint was registered & necessary forms were issued to both the parties.Replies were received from both the parties.The Respondent vide its self-contained noted dated nil received by us on 26.12.06replied that DLA was having past history of illness since last one year and was nothaving any income which he did not disclose in the proposal. Had he disclosed it,underwriting requirements would have been different. Hence, the claim was repudiateddue to concealment of material facts regarding health of DLA without any income.Observations of Ombudsman : I have gone through the materials on records andsubmissions made during hearing and summaries my observations as follows:There is no dispute that the Policy No. 344481789 was issued to DLA by theRespondent on 28.08.2004 and death of DLA occurred on 02.08.2005.During hearing the complainant contended that the DLA has suffered by Jaundice, afternotice of jaundice he was admitted in Majeji Nursing Home, Manasa from 09.07.2005 to11.07.2005 where 2 bottle blood was given. The Complainant has further informed thatthe DLA never suffered from any disease nor taken treatment or was admitted in anyhospital before taking the policy. The DLA was having sufficient income by way ofkirana shop and through Agriculture income.The Respondent contented during hearing that the DLA was sick prior to date ofproposal without income which he did not disclose in the proposal. Had he disclosed it,underwriting requirements would have been different. Hence, the claim was repudiateddue to concealment of material facts regarding health of DLA without any income.On scrutiny of records, it is observed that no evidential proofs, viz., Investigationreport, Blood test report, X-ray, prescription of doctor treating him, etc. have beensubmitted by the Respondent to prove that the DLA was sick prior to the date of policyin question.The Respondent only tried to strengthen its contention on the basis of Dr. MaheshMajeji’s certificate dated 09.11.05 who certified that the DLA was transferred with 2unit of blood from 09.07.05 to 11.07.05 and the Respondent’s Investigation report wasjust based on Dr. Mahesh Majeji’s report and no other evidence was shownrecommending repudiating of the claim.It is apparent from the above that Respondent’s contention merely on the basis of Dr.Mahesh Majeji’s report that the DLA was transferred with 2 unit of blood from 09.07.05to 11.07.05 is not tenable as DLA was a sick prior to proposal.Had the DLA suffered from the disease since one years as contended by theRespondent, some Investigation reports viz., Blood report/X-ray report, doctor’sprescription with regard to treatment, etc. would have been made available to showthat DLA was actually suffering by any disease since one year.It is further observed that the DLA was admitted in Majeji Narsingh Home, Manasawhere 2 bottle bloods was given during the period from 09.07.2005 to 11.07.2005.It is also observed from the records that the DLA was having saving bank account No –1140 in Ratlam- Mandsaur Kshetriya Gramin Bank, Kajarda from where loan was takenby the DLA. Similarly it is also seen from the records that the DLA was having “ bhoo
Page 3 and 4: Repudiation of Claim for Payor’s
Page 5 and 6: Award Dated : 27-11-2006Repudiation
Page 7 and 8: The Complainant’s husband held a
Page 9: sniped at Utmost Good Faith that fo
Page 12 and 13: In view of the above, the decision
Page 14 and 15: concealment of material facts regar
Page 16 and 17: The complaint was registered and ne
Page 18 and 19: he had never suffered from any ailm
Page 20 and 21: from Chronic Hepatitis c Cirrhosis.
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
Page 32 and 33: 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
Page 39 and 40: There was no dispute that the DD fo
Page 41 and 42: proposal the contract remains uncon
Page 43 and 44: the claim stating that her son bein
Page 45 and 46: states that no common poison was fo
Page 47 and 48: the Insurer on the ground that the
Page 49 and 50: On perusing the documents it is obs
Page 51 and 52: application for insurance on 22.12.
Page 53 and 54: preferred a claim with the Insurer.
Page 55 and 56: the time of taking the policies. In
Page 57 and 58: in January 2000. The policy was rev
Page 59 and 60: Subsequently he was referred to Tir
Page 61 and 62: All the spells of medical leave hav
Page 63 and 64: In the hearing, the complainant sta
Page 65 and 66: KTVR Group Hospital due to “Hepat
Page 67 and 68: Chennai Ombudsman CentreCase No. :
Page 69 and 70: He was also on leave during 11.04.2
Page 71 and 72: Life Insurance Corporation of India
Page 73 and 74:
Chennai Ombudsman CentreCase No. :
Page 75 and 76:
found in the body. It was further r
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family doctor. He admitted that his
Page 79 and 80:
Smt.S.Shanthi obtained a life insur
Page 81 and 82:
act. She stated that as per the sta
Page 83 and 84:
evival was almost like a fresh cont
Page 85 and 86:
contended that the deceased life as
Page 87 and 88:
Sri J. Hussain Mohammed submitted a
Page 89 and 90:
and his wife was sitting after her
Page 91 and 92:
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
Page 97 and 98:
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
Page 103 and 104:
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
Page 117 and 118:
the claims excepting the present on
Page 119 and 120:
The submission of LIC is that the p
Page 121 and 122:
LIC that other two policies of Sum
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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
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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
Page 139 and 140:
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
Page 161 and 162:
Life Insurance Corporation of India
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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
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We may mention that the insurance c
Page 171 and 172:
evidence to prove that the DLA was
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The insurance company in their self
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time of taking the policy and that
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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
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and, therefore, she interpreted tha
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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
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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
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treated the person but since the si
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31.03.05/11.04.05 issued under the
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Shri Sarvjit Gupta had lodged a com
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complainant awarded payment of full
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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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