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insurer stated that the life assured was admitted to Government General Hospital,Sankarankoil on 02.09.2003 and he was discharged on 08.09.2003. The doctor hadadvised him to go to Tirunelveli Medical College Hospital for further treatment. He hadsuspected T.B. and referred him to a higher hospital. Within 2 days of his dischargefrom the hospital i.e. on 10 th September 2003 he had proposed for a life insurancepolicy without mentioning the TB or hospitalization. The claims investigating officialhad collected 2 letters from the villages that the life assured was suffering from T.B.for a long time.In this instance the life assured had signed the proposal after getting discharged fromthe hospital which information he had not mentioned in the proposal. Also on08.09.2003, the doctor had discharged him on life assured’s request but againstmedical advice. So it is very evident that the life assured’s health condition was notgood.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.04.2597Sri.L.VellaichamyVsLife Insurance Corporation of IndiaAward Dated : 29.03.2007Smt.V.Muthulakshmi submitted a proposal for life insurance on 10.06.2002 to LIC ofIndia, Dindigul Branch II of Madurai Division. The Insurer issued her a policy numbered743015266 for a sum assured of Rs.50,000/-. Smt.V.Muthulakshmi died of cancer on05.05.2005. Sri L.Vellaichamy the nominee under the policy preferred his claim withthe Insurer. The Insurer rejected his claim on the grounds that the life assured hadwithheld correct information regarding her health at the time of effecting assurancewith them.The complainant Sri. L. Vellaicharmy was not present for the hearing. The contents ofthe letter were that he had approached the Dindugal Branch Office II for death benefitsunder the policy but his claim was denied on the plea that the bills settled to Dr.RaiMemorial Medical Centre, Chennai included a bill dated 22.2.2002 indicating preproposalillness. The complainant had submitted a certificate obtained from Dr.Subramanian, of Dr.Rai Memorial Medical Centre, which has stated that the late Mrs.Muthulakshmi was a tongue cancer patient, and had undergone treatment in theirhospital from 25.10.2002 to April 2003 for external radiation and chemotherapy underDr. Krishnan. During the deceased life assured stay in the hospital, she had undergonelab investigation on 20.2.03, which had been wrongly mentioned in the receipt as22.02.02.The Insurer stated that the deceased Life Assured had taken treatment for tonguecancer at Dr.Rai Memorial Medical Centre, Chennai from 11.10.2002 to 17.10. 2002with external radiation and chemotherapy and paid lab charges on 22.2.2002 at Dr. RaiMemorial Medical Centre, Chennai, which was prior to proposal. Since the Lab Chargesbill showed a date prior to proposal i.e. 22.02.2002 and the claim Form ‘B’ alsosubstantiated that the deceased life assured was suffering from this illness for morethan 4 years, hence, the Insurer had repudiated the claim on the ground that the lifeassured had failed to disclose about his illness at the time of proposal. Insurercontended that they have repudiated the claim based on the date mentioned in the LabCharges bill and in the Claim Form ‘B’ Q. No.5 (f), it was answered as 4 years and
contended that the deceased life assured would been aware of her illness even prior tothe proposal.Dr.Rai Memorial Medical Centre, Chennai is a reputed centre that treats cancer patientand so the Insurer had repudiated the claim as the life assured had got some testsdone there which was proved by the receipt of Dr.Rai Memorial Medical Centre dated22.02.2002. However, as the complainant has now produced proof that it was on20.02.2003 that the lab tests were done and the first consultation at Dr.Rai MemorialMedical Centre was done only in October 2002, the forum finds that whateverevidences for Cancer treatment the Insurer possesses pertain to post-proposal period,which are not relevant for repudiation of the claim.The complaint is allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.04.2590Sri.S.SankarguruVsLife Insurance Corporation of IndiaAward Dated : 29.03.2007Smt.S.Ilavarasi submitted a proposal for life insurance on 27.02.2004 to AruppukottaiBranch of LIC of India. The Insurer had issued her a policy for Rs.50,000/- under theirNew Janaraksha plan. Under this plan age proof is self-declaration made by the lifeassured. Smt.S.Ilavarasi had named her minor son as the nominee. Smt.S.Ilavarasidied on 03.04.2005. Sri S.Sankaraguru, her husband and the Appointee to the minornominee preferred his claim with the Insurer. The Insurer rejected his claim on thegrounds that the life assured had withheld correct information regarding her health atthe time of effecting insurance. His appeal to the Insurer’s higher office was also notfruitful.The complainant Sri. S. Sankaraguru was not present for the hearing. This Forum readout his letter. He has stated that he was a poor farmer and an illiterate. He did notknow the meaning of the policy. His wife died on 03.04.2005 due to cancer. Onsubmission of the claim papers, he came to know that his claim was repudiated. He didnot want to blame anybody for repudiation of his claim. However, he requested thisForum to direct the Insurer to repay at least the premium amount already paid by them,which could be utilized for his son’s treatment of kidney problem. The Insurer statedthat they have repudiated the claim on the grounds that the deceased life assuredfailed to disclose at the time of proposal that she was suffering from Cancer for 3 yearsand had taken treatment in M/s Mohan Nursing Home, where she underwwentChemotherapy, supportive treatment and blood transfusions for Cancer from26.11.2003 to 18.06.2004 The Insurer stated that the deceased life assured hadsuppressed this information in the proposal form.Here the Insurer had proved with medical evidence that the life assured had beensuffering from cancer and also aware of the disease in 2003 itself (prior to proposaldate). Thus by suppressing the true state of her health the life assured had misguidedthe Insurer in wrongly issuing the policy. Had the life assured informed the real state ofher health, the Insurer’s decision would have been different. The life assured’ssuppression had deprived the Insurer a fair chance of evaluating the risk correctly.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.01.2598
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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
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sniped at Utmost Good Faith that fo
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In view of the above, the decision
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concealment of material facts regar
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The complaint was registered and ne
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he had never suffered from any ailm
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from Chronic Hepatitis c Cirrhosis.
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same till death claim arises. The R
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adhikar ewam Rin pustika ” for Ag
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10 days from date of commencement a
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grounds of suppression of material
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the claim for the reason “Suppres
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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 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: evival was almost like a fresh cont
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
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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
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Mumbai Ombudsman CentreCase No. : L
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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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