Death Claim - Gbic.co.in

In the hearing, the complainant stated that her husband had one day slipped andaccidentally fallen down on the other side of the staircase, on the road. He wasbleeding from the leg and head. He was admitted to A.G. Hospitals first and theyadvised him to be admitted to Sri Ramachandra Medical College Hospitals, Chennai.Since he had multiple problems due to the fall he died due to heart attack on20.11.2004. She only knew that he had Umbilical Hernia. The insurer stated that thelife assured died within 7 months and 22 days from the DOC of policy. As per theDischarge Summary of Sri Ramachandra Medical College Hospitals, Chennai the lifeassured died due to Severe Sepsis, DM Type II and Pulmonary Embolism.Dr.M.Chandrasekar of A.G.Hospitals, had stated in Discharge Summary that theassured had a fall from height was treated for fever of 4 days and was diagnosed forUmbilical Hernia, Bilateral Hydrocele, Inguinal Hernia and Renal Azotemia -–known DMnot on any treatment. All these illnesses were not mentioned in the proposal form.Thus it is evident that the Insurer had repudiated the claim based on documentsrelating to a period after the proposal date. The Insurers, in this case, failed toconclusively prove with the aid of clinching documentary evidence that there wasmaterial suppression by the assured to render the contract of insurance voidable.However in view of the fact that there was suppression of Diabetes, Hernia andHydrocele by the assured in his proposal and the ailment ‘Diabetes’ has seriousconnotations when it comes to the underwriting consideration of the insurer, this Forumdecides that an amount equal to Rs.12000/- be given to the complainant in full andfinal settlement of the claim on ex-gratia basis.The complaint is partly allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.05.2406Smt.R.PalaniammalVsLife Insurance Corporation of IndiaAward Dated 29.01.2007Sri. P.Ramakrishnan was a Mazdoor in a Co-Operative Sugar Mill when he submitted aproposal for Life Insurance on his life on 31.03.2004 to LIC of India, Harur Branch ofSalem Division. The Insurer issued him a policy numbered 701718657 under theirEndowment Plan for a SA of Rs.50000/-. Sri. P.Ramakrishnan died on 26.10.2004. Hisnominee, Smt. R.Palaniammal preferred the death claim with the Insurer. The Insurerrejected her claim on the grounds that the life assured had withheld correctinformation, regarding his health at the time of proposing for his insurance.In the hearing the complainant’s brother Sri Senthil M represented her. He stated thatthe LA took policies for the sake of collateral security for the home loan he sought fromDewan Housing Finance Ltd. He was suffering from stomach pain on and off. Normallyanybody would not immediately suspect serious illness and would try to take medicinesso that the pain would subside. Since the pain was persistent they had admitted him toStanley Hospital on 28.04.2004 and later he was again admitted to Stanley Hospital on26.08.2004 for stomach pain. The insurer stated the claim under policy no.701718657was repudiated based on the non-disclosure of details of his stomach pain in theproposal (for 3 months as per the Discharge Summary of the Stanley Hospital).A perusal of the above documents reveal that the life assured had been suffering fromstomach pain, prior to the date of proposal. Regarding the actual diagnosis of thesymptom as Tuberculosis was done only in September 2004- after issue of the policy.