Death Claim - Gbic.co.in

Life Insurance Corporation of IndiaAward Dated : 23.03.2007Smt. Leela Bai, resident of Gram- khurdi Awar, Tah.- Mahoo Distt.- Indore [hereinaftercalled Complainant] is the wife of Late Shri Mangilal, Deceased Life Assured (in shortDLA). The DLA had a life insurance policies number 344096094 and 344096095 takenfrom LIC of India, DO: Indore, BO Mahoo [hereinafter called Respondent]. The Policiescommenced on 15.03.2004 under Table/Term: 93-25 for Sum Assured of 40,000/-each.The DLA expired on 08-05-2005 due to fever, Altered Sensorium Colvulsion. The deathof DLA occurred after 1 year 1month and 23 days from the commencement of thepolicies. The death claim was preferred by the Complainant with the Respondent butthe same was repudiated on the grounds of suppression of material facts regardinghealth of DLA at the time of taking the policies. Aggrieved by the repudiation action ofRespondent, the Complainant has lodged a complaint with this Office seekingdirections to Respondent to settle the claim amount under the policies.The complaint was registered and necessary forms were issued to both the parties.Replies were received from both the parties.The Respondent vide its self-contained note received on 12-03-2007 replied that DLAhad not disclosed his illness in the proposal forms dated 10-03-2004 submitted forinsurance and has stated his state of health was “GOOD”. Had the history of his illnessbeen disclosed at the time of proposing for insurance, decision for acceptance of thecase would have been affected. Hence, the claim under both the policies wasrepudiated due to non-disclosure of material facts.The Respondent submitted the records of M.Y.Hospital, leave records from theEmployer with Medical certificate from Dr. J.L.Patidar dated 05-05-2004 for which theDLA availed Earn leave on medical ground from 01-03-2004 to 05-05-2004 for 66 dayswith reason Pyrexia of unknown origin (PUO).The policies in question were proposed on 10-03-2004 where as the DLA did notmentioned any thing about his past illness. Considering all these facts LIC repudiatedthe claim for the reason “Suppression of material facts” regarding his health. Further,the case was referred to the claim review committee at LIC zonal Office Bhopal. TheZO CRC in its meeting upheld the DO decision of repudiation on 22-12-2006.Observations of Ombudsman : have gone through the materials on records andsubmissions made during hearing and summaries my observations as follows:There is no dispute that the policy number 344096094 and 344096095 were issued toDLA by the Respondent on 15.03.2004 and death of DLA occurred on 08-05-2005 dueto fever, Altered Sensorium Convulsion.During hearing the complainant stated that the DLA was an employee of P.H.E.Deptt.as Helper posted at Mandleshwar and he was not suffering from any disease and wasin good health at the time of taking the policies in question. The Complainant furtheradded that the DLA was suffering from cold, cough and fever occasionally.During hearing, the Respondent contended that there are sufficient evidencesconfirming that the DLA was suffering from fever, Altered Sensorium Colvulsion prior totaking the policies. However, the history of aforesaid diseases/ailments was notmentioned by the DLA in the proposal forms dated 10-03-2004 for both the policies.The DLA was diagnosed for aforesaid diseases/ailments and hence the claim wasrepudiated due to concealment of material facts regarding health of DLA. Had theDLA’s ill health and treatment details been brought to the knowledge of theRespondent in the proposal form submitted by the DLA, the underwriting decision ofthe Respondent would have been different.