Death Claim - Gbic.co.in

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Sri. R.Rajendran submitted a proposal for Life Insurance on his life on 27.01.2003 toLIC of India, Career Agents Branch of Tirunelveli Division. Along with the proposal hesubmitted a medical report of even date from the Insurer’s panel doctor. The Insurerissued him a policy numbered 321328517 under their Endowment Plan for a SA of Onelakh. Sri. R.Rajendran died on 5.12.2005 due to Cardiac Pulmonary Arrest. Hisnominee, Smt. R.Jeyamary preferred the death claim with the Insurer. The Insurerrejected her claim on the grounds that the life assured had suppressed materialinformation, regarding his health at the time of proposing for his insurance. Unhappywith the Insurer’s decision Smt. R. Jeyamary represented to this Forum and agreed tohave the Ombudsman as a mediator.In the hearing the Complainant told the Forum that her husband went to Hospital totake treatment for the sore in the knee. To the question why her husband had availedlong leave the Complainant replied that he availed leave as it was in excess and hewas due to retire. The Insurer presented the case and briefed the reason forrepudiation. Investigation report stated that the life assured was a Diabetic patient formore than 20 years and this was not disclosed in the proposal form.On perusing the relevant documents, it was evident that the Insurer had issued thepolicy after medically examining the life assured. Also the Insurer had repudiated theclaim based on their Claim Investigating Officer’s Report and the Krishna MaternityHome and Pediatric Centre’s case sheet. This case sheet can not be accepted as aconclusive evidence as the patient had been unconscious at the time of admission andthe veracity of the recordings in the case sheet have no corroborative proof. It wouldbe difficult to concur with the Insurer’s decision to repudiate the claim for suppressionof material fact, merely based on the case sheet of the hospital to which the LA wastaken in an unconscious state and from where he never recovered.The Complaint is Allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.04.2407Smt. M.RajeswariVsLife Insurance Corporation of IndiaAward Dated : 22.01.2007Sri.S.Mariappan who was working as an Attender in a Co-Op Bank, submitted aproposal on 19.02.2005 to LIC of India, City Branch-IV of Madurai Division andobtained a Policy numbered 743634688. The policy was for a sum assured ofRs.150000/- with a yearly premium of Rs.9043/- . Sri.S.Mariappan died on 21.04.2005.Smt. M.Rajeswari, the nominee under the policy submitted her claim papers to theInsurer. The Insurer repudiated the claim on the grounds that the life assured hadwithheld correct information regarding his health.In the hearing the complainant told that her husband was in good health and he availedleave only to go on tours and not for taking any treatment. She added that he was notactually suffering from any ulcer nor was he taking any treatment for that. The Insurerbriefed the case and pointed out that the assured had not mentioned in his proposalabout the several spells of leave on medical grounds availed by him and thus deprivedthem of a fair chance of scrutiny. The Forum informed that a claim should not berepudiated only on the basis of medical certificate. The Insurer said that the assuredhad been producing medical certificates from 2001 stating the same reason i.e. Ulcerand also the medical certificates produced by the assured were not from the samedoctor.
All the spells of medical leave have been for the same reason-“Acid Peptic Disease”.However no further details such as diagnostic tests done, and the exact medicinesprescribed etc were available. The insurer was also not able to produce any suchdetails. It is worth observing here that it is not uncommon among employees to availleave on medical grounds even for attending to personal work. However, the factcannot also be ignored that the assured did not mention in the proposal the medicalleave availed by him, about which there is a specific question in the proposal. Thesame disease is mentioned in all the medical certificates even though the doctors whosigned them are different. The life assured was working in a Co-operative Bank whereit may not be possible to avail leave unless there is a genuine need measure. As such,this Forum decided that an amount of Rs.15000/- be made available to the complainanton an ex-gratia basis.The complaint was partly allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.07.2391Smt. Amali Asha ChitraVsLife Insurance Corporation of IndiaAward Dated : 25.01.2007Sri Arockia Selvam submitted a proposal for Life Insurance on his life on 20.9.1999 toNagercoil City Branch of LIC of India. The Insurer issued him a policy for a SumAssured of Rs. 1 lakh bearing number 320678764 under Jeevan Mitra Plan. He revivedthe policy twice- once on 04.09.2001 and once on 14.12.2002. The LA submitted a“Personal Statement of Health” dated 13.12.2002. On 05.08.2004 Sri. G. ArockiaSelvam committed suicide by hanging. Smt. Amali Asha Chitra his wife and nomineepreferred the claim with the insurer. The Insurer rejected her claim on the grounds thatthe life assured had made deliberated misstatements and withheld material informationregarding his health at the time of reviving his policy.In the hearing, the complainant reported that the assured, a constable with BSFdisliked working in the border area and often used to avail leave to be with the family.The Forum enquired about the deceased’s health and behavioral patterns, details oftreatment that he had undergone and grounds of termination of his services from BSF.The insurer informed that the death was due to suicide. The policy was revived twiceinMarch 2001 & September 2002 on the basis of “Declaration of Good Health. Thetreatment taken for mental depression before the date of revival was not disclosed bythe deceased.From the available documents it is evident that the life assured was suffering frommental illness from the year 2000 and was not keeping good mental health. Bysuppressing this important and material fact in his “Personal Statement of Health” thelife assured had misguided the Insurer in reviving the policy on existing rates. Had theInsurer been aware of the LA’s mental condition then their underwriting decision wouldhave been different and they perhaps may not have accepted to revive at all. Also thecause of death is suicide. There is a definite nexus between the illness suppressed andcause of death. Thus the life assured by misrepresenting his real state of healthdeprived the Insurer a fair chance of correctly appraising the risk.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.04.2344
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Repudiation of Claim for Payor’s
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Award Dated : 27-11-2006Repudiation
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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 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: Subsequently he was referred to Tir
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
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Thus, he withheld facts and was gui
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questions provided in item no.11 of
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the claims excepting the present on
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The submission of LIC is that the p
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LIC that other two policies of Sum
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Branch Office of LICI. It is stated
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We have considered the photocopies
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On the circumstances aforesaid, it
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Life Insurance Corporation of India
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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
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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
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Life Insurance Corporation of India
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hypertensive before the inception o
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Ltd and expired on 30.09.04. Theref
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Kotak Mohindra Old Mutual Life Insu
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We may mention that the insurance c
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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
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their own guidelines can consider t
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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
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We were unable to modify the order
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certificates submitted by the claim
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Smt. Phoolpatti had lodged a compla
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dispute the will but contended that
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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
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Award dated 31.02.2007Smt. Shakunta
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asis of which proposal was complete
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Consultation/Treatment as proof of
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Smt Shantona Kanaiya Ghosh had take
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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
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Jhatingrao Gaikwad to pursue the ca
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into consideration, it would be rea
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Mumbai Ombudsman CentreCase No. : L
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