Death Claim - Gbic.co.in

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Award Dated : 28.11.2006Ms.D.Kadambari, when employed in M/s.Slash Support India Pvt. Ltd, obtained ainsurance Policy from LIC of India, Branch- XXI of Chennai D.O.-I. She signed aproposal on 11.06.2004 for the same. The policy numbered 713991464 had SumAssured as Rs.2.5 lakhs. The life assured died on 22.02.2005 at Apollo Hospitals,Chennai due to 50% burns and Septicemia. Sri.A.Dhananjayan, the nominee under thepolicy submitted his claim to the Insurer. The Insurer rejected the claim as the lifeassured had suffered from Schizo-effective disorder (mood disorder) and had beenhospitalized for treating the same. She had not disclosed any of these in her proposaldated 11.06.2004.In the hearing on 20.10.2006 the complainant, admitted that his daughter washospitalized and had taken treatment as she had complaints of sleeplessness. He saidthat his daughter was highly qualified and since she was in the software professionthere was some disturbance in the sleeping pattern. When it was pointed out that hisdaughter had not revealed the treatment she had undergone, in the proposal, he saidthat since it was an ordinary treatment, she might not have felt it necessary to mention.The insurer stated that the life assured died within 8 months and 10 days of taking thepolicy. The life assured had suffered from Schizo effective disorder (mood disorder)before proposing for insurance on 11.06.2004. The relevant details were not disclosedin the proposal form. Had they been disclosed, their underwriting decision would havebeen different.On going through the documents it emerges that the life assured had suffered from anillness which is not a passing ailment like cold, cough, fever etc. which could haveescaped her memory at the time of proposing for insurance. So her father’s contentionthat it was an ordinary treatment which she might not have felt necessary to mention inthe proposal is difficult to accept. Even though there is no nexus between the cause ofdeath and illness suppressed the Insurer has proved with clinching medical evidencethat there was material suppression of facts and by suppressing these importantinformation the life assured had deprived the Insurer of a fair chance of havingevaluated the risk correctly.Chennai Ombudsman CentreCase No. : IO (CHN)/21.003.2264.Smt.B.ManimekalaVsTATA AIG Life Insurance Co. Ltd.Award Dated : 14.12.2006Sri G.Kameshwaran applied to Tata AIG Life Insurance Co. for a Life Line plan on22.12.2005. According to the policy issued on 23.12.2005 the Life Assured was entitledto get the refund of premiums on surviving the term and 2 lakhs on death during theterm of the policy (4 Lakhs in case of death by accident. Sri G.Kameshwaran died on03.04.2006 at Apollo Hospitals due to Acute Lymphoblastic Leukemia (ALL) withrelapse with Refractory disease. His mother preferred the claim with the Insurer. TheInsurer rejected her claim on the grounds that the life assured had not revealed in theapplication for insurance dated 22.12.2005 that he had been under treatment for ALLsince 2000 and that he underwent Orchidectomy for relapse in 2003.In the hearing, on 17.10.2006 the representative of the complainant stated that his sonviz. the life assured was working as a Software Engineer at Chennai after completinghis B.E. His son approached. Citi Financial for a loan to buy a Car. Since Citi Financialwas an agent of Tata AIG they had offered insurance to his son. His son signed the
application for insurance on 22.12.2005. His son had not disclosed his past illness inthe application because he was in normal health when he took the policy. The insurerstated that the life assured had not disclosed in his application for insurance dated22.12.2005 the details of his treatment for Acute Lymphoblastic Leukemia since 2000and undergoing Orchidectomy in 2003 for relapse. The assured was a SoftwareEngineer and a highly educated person and it was not acceptable that he has justsigned the proposal without going through the contents in the proposal. Whenquestioned about Citi Financial and the nature of insurance policy sold by them, heclarified that it was not a group policy or a collateral security policy.It is therefore clear that the life assured was affected by a serious disease; which couldbe controlled but not cured. It is therefore difficult to accept the argument of therepresentative of the complainant that the life assured was normal on the day hesigned the application. Perhaps the life assured had no fraudulent intention when heapplied for insurance as it was taken at Citi Financials, the financial company he hadapproached to advance him funds to buy a car. However there is clear medicalevidence to show that he was suffering from Leukemia well before signing theapplication for insurance.Chennai Ombudsman CentreCase No. : IO (CHN)/21.05.2353Smt. D.AnguVsLife Insurance Corporation of IndiaAward Dated : 22.12.2006Sri. S. Duraisamy signed a proposal for the Insurance Policy on 27.07.2003, andsubmitted it to LIC of India, Salem North Branch. He was issued a policy bearingnumber 701356661 for a SA Rs.30,000/- under Endowment Plan. Sri. S. Duraisamydied at his residence on 02.05.2004, due to Chest Pain. Smt. D. Angu, his wife andnominee under the policy preferred her claim with the Insurer. The Insurer rejected herclaim on the grounds that the life assured had suppressed the Major Road TrafficAccident met by him in 1995, in which he had sustained severe injuries to his left armand leg.In the hearing on 15.11.2006, Smt. D. Angu was not present and her representationwas read out. In that letter, she had stated that her husband Mr. Duraisamy had metwith an accident on 23.06.1995. Smt. Angu also stated in her letter that her husbandwas going to his office from 1995 to 2004 regularly and he was healthy. The Insurerstated that as death occurred within 9 months from the date of commencement of thepolicy they had arranged for an investigation and by that they learnt that during theyear 1995 the life assured had met with a major road accident. However, it was notdisclosed by the life assured at the time of proposal.The Insurer had repudiated the claim merely because the life assured had notrevealed the accident that had occurred 8 years ago as on the date of the proposal.The Insurer had not produced any evidence to conclusively prove that the accident wascausing the life assured medical discomfort and had hastened his death. The Insurerhad not produced any prescription to show that the medicines taken for the injuriescaused in the accident had reduced the normal life span of the life assured. Thus therewas no justification for the insurer to repudiate the claim. Thus their decision torepudiate the claim does not stand the text of ethical and legal scrutiny and the sameis untenable in law and as well on facts.The complaint was allowed.
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 22 and 23: same till death claim arises. The R
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: On perusing the documents it is obs
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
Page 77 and 78: 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
Page 93 and 94: VsLife Insurance Corporation of Ind
Page 95 and 96: Jodhpur on 11.11.2002 and was disch
Page 97 and 98: He had concealed the material fact
Page 99 and 100: They further needed claim forms No.
Page 101 and 102:
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
Page 107 and 108:
3 months and 14 days of taking poli
Page 109 and 110:
09.06.2003 and the proposal was sub
Page 111 and 112:
Leukemia. Bone Marrow Report dated
Page 113 and 114:
Thus, he withheld facts and was gui
Page 115 and 116:
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
Page 123 and 124:
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
Page 133 and 134:
information. The insurer also suspe
Page 135 and 136:
The claim was rejected by LIC stati
Page 137 and 138:
Facts of the Case: (Late) G.Appa Ra
Page 139 and 140:
Head Notes: Life assured availed a
Page 141 and 142:
in English, which suggest that he i
Page 143 and 144:
LIC about usage of herbal medicines
Page 145 and 146:
age proof. She requested for settle
Page 147 and 148:
the owner of the opposite vehicle i
Page 149 and 150:
action was found to be based on pro
Page 151 and 152:
certificate issued by one Dr.H.R.De
Page 153 and 154:
suffering from disease prior to rev
Page 155 and 156:
establish that the LA failed to dis
Page 157 and 158:
The complaint under Rule 12(1)(b) r
Page 159 and 160:
not be blamed entirely. But, the mi
Page 161 and 162:
Life Insurance Corporation of India
Page 163 and 164:
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
Page 169 and 170:
We may mention that the insurance c
Page 171 and 172:
evidence to prove that the DLA was
Page 173 and 174:
The insurance company in their self
Page 175 and 176:
time of taking the policy and that
Page 177 and 178:
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
Page 183 and 184:
and, therefore, she interpreted tha
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 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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