Death Claim - Gbic.co.in

alone knew his health condition, should inform the Insurer the real state of his health toenable the Insurer to correctly assess the risk.The complainant was convinced about the need to disclose all the relevant changes inhealth conditions to the Insurer at the time of reviving the policy and agreed to acceptthe paid up value and bonus as the claim amount. The Insurer expressed theirwillingness to settle the agreed amount.It was therefore recommended that the Insurer shall obtain consent from thecomplainant and settle the paid up value with bonus as the full and final settlement ofthe claim, as agreed by the complainant.Chennai Ombudsman CentreCase No. : IO (CHN)/21.009.2464Smt.P.NirmalaVsBajaj Allianz Life Insurance Co.Award Dated : 12.02.2007Sri.R.Paramasivam signed on 20.05.2005 a proposal for life insurance and submitted itto Bajaj Allianz Life Insurance office of Chennai. The Insurer issued him a policynumbered 0009379361 under ‘Cash Gain Economy Plan’ with Family Income Benefitand Comprehensive Accident Protection as Riders. Sri.R.Paramasivam died on25.03.2006. Smt. P.Nirmala, the nominee under the policy submitted her claim papersto the Insurer. The Insurer repudiated the claim on the grounds that the life assuredhad not disclosed material facts in his proposal for insurance dated 20.05.2005.In the hearing the complainant told the Forum that her husband was a business manand a contract labour and his death was a sudden one. She agreed that her husbandwas a smoker but used to smoke during night shifts. One of the Officials of the Forumquestioned whether her deceased husband was using hearing aid machine. She repliedthat he was using the hearing aid machine whenever required. She also contended thathe was healthy before his death. The Insurer stated that since it was an early claim i.e.9 months after the proposal, they arranged for an investigation, whereby it wasrevealed that the deceased was a smoker, deaf since childhood and had Chest painearlier. They had also produced to this forum the medical certificate obtained from aGovt. Doctor to prove his deafness. The Insurer also stated that had these details beendisclosed at the time of proposal, they would have asked the Life assured to undergomedical examination like FMR, ECG and would have called for smoking and disabilityquestionnaire.So it was evident that the life assured had not revealed his deformity in the proposalfor insurance dated 20.05.2005 (Here, it is worthwhile to note the general principle thata party of full age and understanding is normally bound by his signature to a documentwhether he reads it, understands it or not). However regarding the Coronary ArteryDisease, the Insurer had neither hospital reports, ECG/other test reports nor medicalprescriptions to conclusively prove that life assured was suffering from Coronary ArteryDisease before proposing for insurance. Further adequate evidence was not producedby the Insurer for proving (a) smoking alone was the cause for Coronary Artery Diseaseand (b) exact onset of the symptoms of heart disease which led to heart attack whichwas the proximate cause of death. To be fair and equitable to both the parties, giventhe circumstances of the case, it was decided that an amount equal to Rs.25000/- beallowed to the complainant as an ex-gratia payment.The complaint is partly allowed.