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to pay an ex-gratia of 3 Lakhs. In the hearing the Insurer stated that it was a TripleCover Policy for Rs.3 Lakhs Sum Assured. Rs.2,84,034/- had been received as Singlepremium. The policy had run for 1 month and few days. On going through the previousmedical check ups, they found that the assured had health problem prior to proposingfor this policy. They had carefully examined the facts of the case before deciding onex-gratia payment of Rs.3 Lakhs.Beyond the two Health Check-up reports (which were given by the claimant herself) theinsurer had no medical evidence to conclusively prove that the assured was ailing fromsome serious ailment for which he undertook treatment and further that the ailment wasof such a serious nature as to affect their underwriting decision. The insurer failed toprove with any clear-cut evidence that the assured suppressed material information,with a fraudulent intention.The Complaint is allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.08.2357Sri.T.V.RenuVsLife Insurance Corporation of IndiaAward Dated : 26.12.2006Smt.D.Aiyammal submitted three proposals in August 2004 to LIC of India CheyyarBranch under Vellore Division to obtain three policies under ‘Bima Plus’ Plan. Theamount payable as death benefits under the plan will be the bid value of thepolicyholder’s unit account as on the date of death together with an amount equal tofull SA or a portion depending on duration run by the policy. The life assured died on30.07.2005 that is within 11 months and 18 days. Sri T.V.Renu, as the Appointee forthe minor nominee approached the Insurer for death claim. The Insurer paid the bidvalue of the policyholder’s unit account as on the date of death, but rejected to pay the60% of Sum Assured, on the grounds that the life assured had withheld correctinformation regarding her health at the time of effecting insurance.In the hearing on 28.11.2006 as the representative of the complainant was not presentfor the hearing one of the officials read out the letter dated 02.11.2006. He had statedin his letter that the life assured had taken 3 Bima Plus Single Premium Policies withLife Cover. She died on 30.7.2005 within 11 months after the commencement of thepolicy. The complainant received cheques for the Market Value of the shares under allthe 3 policies and asked for clarification pertaining to the policy which states that incase of Death of the life assured, the nominee/heirs would get 60% of the Sum assuredand the Bid value of the policy holder’s unit account as on the date of death. Theinsurer stated that in this policy one portion of the premium covered life and rest of theamount was invested in UNIT linked business which would be invested in the sharemarket and the benefit returned to the policy holders. However the Insurer stated thatthe Life assured submitted the proposal forms during the month of August 04 and inthose forms the Life Assured had not mentioned about her treatment for AIDS. Therepresentative of the complainant had stated in the claim form that the claimant dieddue to stomach pain but after investigation they had found out that the life assured hadbeen diagnosed to be HIV positive prior to the proposal.A careful consideration and scrutiny of all the available evidence, establish that theInsurer had beyond doubt proved that the assured was indeed suffering from AIDS at
the time of taking the policies. In the result, the complaint fails and the complaint isthus disposed off on merits as aforesaid.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.08.2369Smt.S.SarathaVsLife Insurance Corporation of IndiaAward Dated : 29.12.2006Sri N. Singaravadivelu took a Jeevan Suraksha Policy (Pension Policy) from LIC ofIndia, Panruti Branch, under Vellore Division, by submitting a proposal for theinsurance on 03.03.2001. Sri N. Singaravadivelu died on 19.09.2001. Smt. S. Saratha,his wife and the nominee, preferred her claim with the Insurer on 20.07.2003. TheInsurer rejected the claim on the grounds that the life assured had withheld materialinformation regarding his health at the time of effecting the insurance.In the hearing on 28.11.2006, the complainant stated that her husband was quitehealthy. The last posting had been stressful and he used to complain of tiredness andheadache. He used to bring files home. When questioned as to why they preferred theclaim very late, she said that their only son was trying to get employment in TNEB oncompassionate grounds. Dr.Nayab who was a good friend of her husband had givenClaim Form B which the insurer had lost. Again the Insurer had obtained a Claim formB from the same Doctor. The information given in the two forms were contradictory.The insurer stated that the risk under the Jeevan Suraksha policy with life covercommenced on 09.03.2001 under medical scheme with death benefit payable as 50%of the targeted pension. The policy had run for hardly 6 months. As per the Claim FormB given by Dr.Nayab he had treated the life assured since 1999-2001 for Hypertensionand Diabetes and this he confirmed vide his letter dated 07.07.2004.It is evident that the life assured was diabetic and hypertensive before proposing.However the insurer had relied on mere claim forms to repudiate the claim. Equity andnatural justice call for consideration of the case keeping both the parties in mind and,the Insurer was, therefore, directed to pay the complainant an amount of Rs. 15,000/-under the policy in full and final settlement of the claim.The complaint was partly allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.08.2385Smt.T.AmbikaVsLife Insurance Corporation of IndiaAward Dated : 11.01.2007Smt. Kolanjiammal submitted a proposal on 31.03.93 to LIC of India, VriddachalamBranch to Policy bearing number 730214360. The policy was for a sum assured ofRs.25000/- with a quarterly premium of Rs.385/- . Age proof submitted by her washoroscope. Smt. P. Kolanjiammal died on 18.08.2005. Smt. Ambika, the nominee underthe policy submitted her claim papers to the Insurer. The Insurer repudiated the claimon the grounds that the life assured had with held material information regarding herage at the time of effecting the assurance with them.
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 and 50: On perusing the documents it is obs
Page 51 and 52: application for insurance on 22.12.
Page 53: preferred a claim with the Insurer.
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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