Death Claim - Gbic.co.in

the claim for the reason “Suppression of material facts” regarding his health. Further,he case was referred to the claim review committee at LIC zonal Office Bhopal. The ZOCRC in its meeting upheld the DO decision of repudiation on 22-12.2006.Observations of Ombudsman :I have gone through the materials on records and submissions made during hearingand summaries my observations as follows:There is no dispute that the policy number 202033231 was issued to DLA by theRespondent on 15.03.2003 and death of DLA occurred on 07-10-2004 due to stomachpain.During hearing the complainant contended that the DLA was throughout keeping normalhealth and that he availed leaves from Office on medical grounds for reasons otherthan sickness. The complainant further informed that the DLA was having total fourpolicies bearing no. 202031709, 202031214, 202032003 and 202033231 out of whichthe Respondent has paid the death claim under three policies except the policy no.202033231.The Respondent contented during hearing that the DLA was suffering from entericfever. The policy in question was proposed on 08.03.2003 where as the DLA did notmentione any thing about his past illness. The DLA also availed the leaves on medicalground for the same. Hence the death claim was repudiated for the reason“Suppression of material facts” regarding his health.It is observed from records that DLA was an employee of BSNL as a cashier and hewas suffering from Enteric fever prior to the date of proposal. As per leave recordsobtained from the Employer of the DLA it was confirmed that the DLA has availed theleaves on medical ground for the period 04-03-2003 to 12-03-2003 ( 9 days), 13-03-2003 to 24-04-2003n (43 days)and 01-05-2003 to 27-05-2003.It is also observed from the Medical Certificate issued by Dr. A.K.Jain dated 04-03-2003 and 08-03-2003 for which the DLA availed leaves on medical ground from04.03.2003 to 12.03.2003 with reason Enteric fever, whereas in the proposal formsigned by DLA on 08-03-2003 in which the answer of question no. 11 ( c ) i.e. have youbeen absent for the last 5 years from your duties on the medical ground ? Saying ‘ NO ’to this question shows that the DLA had never suffered from any ailment whatsoever inthe past and that he was absolutely keeping normal health is not tenable.This clearly shows that DLA was already suffering from Enteric fever but intentionallysuppressed in the Proposal forms under Policy in question.Insurance is a contract of Utmost Good Faith where both parties are required todisclose all the material facts. No party can be allowed to gain any undue advantage bysuppressing any fact. In the present case, there are sufficient evidential proofs to showthat the DLA was already suffering from serious ailments but suppressed in theProposal form. Had the same been brought to the knowledge of the Respondent, theunderwriting decision would have been different.In view of the circumstances stated above, I am of the considered opinion that thedecision taken by the Respondent is just and fair hence does not require anyinterference.The complaint is dismissed without any relief.Bhopal Ombudsman CentreCase No.: LI-1231-21/02-07/INDSmt. Leela BaiVs