Death Claim - Gbic.co.in

KTVR Group Hospital due to “Hepatocellular Failure”. Smt. V.Kousalya, the nomineeunder the policy preferred her claim with the Insurer. The Insurer rejected her claim onthe grounds that the life assured had not revealed that he had suffered from PulmonaryTB with Haemoptysis in the application for insurance dated 17.10.2005.The complainant Smt. V.Kousalya was not present for the hearing. One of the ForumOfficials read out the contents of the complainant’s appeal. The complainant’s maincontention was the way she was treated at the time of investigation, conducted by theInsurer. She also has agreed in her letter that her husband had TB, was undermedication, and as TB is a curable disease, her husband would not have disclosed thesame in the proposal form. The insurer mentioned the details of the policy such as thedate of proposal (14.10.2005), the commencement of the policy (8.11.2005). The lifeassured died on 04.06.2006. On the submission of the claim papers they observed thathis death was due to Hepatocellular failure. Since, it was an early claim they arrangedfor an investigation. As per the discharge record of KTV Medical Foundations Pvt. Ltd.,where it was clearly stated that the policyholder was a case of Cirrhosis of liver, DM,Old Pulmonary Tuberculosis with Haemoptysis. The life assured replied negatively tothe concerned question in the proposal form.It was therefore evident that the life assured had not mentioned that he had sufferedfrom Tuberculosis to the question-3 b) “Have you ever had or sought advice for thefollowing: ‘Asthma, chronic cough, pneumonia shortness of breath, T.B.,or any otherrespiratory or lung disorders?’” in the application for insurance. Had he disclosed thisvital information the Insurer would have called for relevant medical reports and wouldhave accepted at terms different from the present one. By not revealing the exact stateof his health the life assured had deprived the Insurer of correctly assessing the risk.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.08.2498Smt.P.LathaVsLife Insurance Corporation of IndiaAward Dated 29.01.2007Sri.S.Ponmuthu submitted a proposal for insurance on his life on 31.01.1992 atVillupuram Branch of LIC of India. The Insurer issued him a policy for Rs.50000/- underJeevan Mitra Plan. The policy was allowed to lapse due to non-payment of premiumand then revived on 01.03.1995, 28.02.1996, 03.03.1997, 24.02.1998 and lastly on14.12.2004 on the strength of a “Personal Statement of Health”. Sri.S.Ponmuthu diedon 19.06.2005. Smt.P.Latha, his wife and the nominee preferred the death claim withthe Insurer. The Insurer repudiated to settle the full claim on the grounds that the lifeassured had got his policy revived on 14.12.2004 without informing them about his“Nephrotic Syndrome and Hypertension. However the Insurer offered to pay the paid upvalue and bonus that the policy had acquired before it had lapsed.In the hearing the Insurer submitted the various documents on which they had reliedupon to set aside the revival done on 14.12.2004. The complainant, Smt.P.Latha,agreed that her husband had undergone nephrectomy in 2000 but she said that theywere not aware that they should disclose all the treatment particulars in the “PersonalStatement of Health”. The Forum explained to the complainant the concept ofinsurance. It was explained that the Contract of Insurance is a contract of utmost goodfaith and it was essential that the life to be insured -in this case the life assured, who