Death Claim - Gbic.co.in

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functioning of organs. This non-disclosure of the ailements by the assured, no doubt,denied the Insurer of the chance of proper risk assessment and thus there was a clearbreach of the principle of ‘utmost good faith’. At the same time, there was no evidenceproduced by the Insurer to prove the ailment of the assured, besides the solitaryinstance in August, 2002, and as such, that the contention of material suppressioncould not be given credence to, the Ombudsman opined. And hence, an ex-gratiaamount equivalent to 60 % of the sum assured was awarded. The Insurer was directedto pay Rs. 30,000/-.The complaint was partially allowed.Chennai Ombudsman CentreCase No. IO (CHN) / 21.04.2148 / 2005 - 06Smt. S. SelviVs.Life Insurance Corporation of IndiaAward Dated 11.08.2005Smt. S. Selvi, W/o Late R Suriyamurthy approached our Forum with a complaintagainst repudiation of death claim on her husband’s policy, taken at Madurai Unit IIIBranch. The risk under the policy commenced on 28.12.2003 and the death of theassured occurred on 12.07.2004. The Insurer had denied the claim on the pretext thatthe assured had not disclosed the details of his Diabetes, Cardio-vascular shock andHemiplegia and the treatment availed before proposing for insurance.A personal hearing of both the parties was held at Madurai on 29.07.2005. Thecomplainant pleaded that her husband did not understand English but could only signand that the proposal was filled in by the agent and not by her husband. At the sametime she admitted that her husband was given treatment and physiotherapy forparalysis of right hand in 1998 after which he became alright. The Insurer couldproduce to this Forum the documentary evidence such as Hospital Admission Record,Case Summary, Discharge Record etc., to prove the pre-proposal illness the assuredhad suffered from. According to the Hospital Certificate, Diabetes was a co-existingdisease, contributing to the cause of death.The Ombudsman observed that there was a clear breach of the golden principle of‘utmost good faith’ in this case as the cause of death was not totally unrelated to thepre-proposal ailments the assured had suffered and the same being not disclosed inthe proposal form.Thus the complaint was dismissed.Chennai Ombudsman CentreCase No. IO (CHN) / 21.06.2090 / 2005 - 06Smt. R. ValarmathiVs.Life Insurance Corporation of IndiaAward Dated 12.08.2005A complaint was preferred by Smt. R. Valarmathi, W/o Late N. Rengarasu, against theThanjavur DO of LIC of India, regarding the denial of death claim on her husband’spolicy. Her husband had taken a policy with commencement date 28.02.2003. He diedon 12.07.2003 due to Lung Cancer and Secondaries in brain. The Insurer hadrepudiated the claim on the ground that the assured had not disclosed details of hisavailing medical leave on many occacsions prior to proposing for insurance.
A hearing of both the Insurer and the complainant was held on 28.07.2005, thecomplainant deposed that her husband was working in a cement factory and was haleand healthy till April, 2003. His condition started deteriorating since then and finallywas diagnosed for cancer. They had consulted Kovia Medical Centre, Adyar CancerInstitute and finally Roy Medical Centre, Chennai, who opined that there was no scopefor treatment. Though her husband had availed leave in 2001 and 2002, he had availedmedical leave at a stretch for 4 days on only one occasion. The cancer could bedetected only at the secondary stage, she added. The Insurer argued that the assuredhad availed medical leave for 36 days, 31 days and 92 days in the years 2001, 2002and 2003 and the same was not disclosed in the proposal form and hence therepudiation.The Ombudsman observed that the Insurer could not prove the grounds of materialsuppression as no evidence of treatment could be borught forth by them. He furtherremarked that the proposal was accepted with a health extra premium of Rs. 07.50 perthousand only after a satisfactory medical examination of the assured including specialreports by the Insurer’s approved medical examiner and ordered payment of basic sumassured with attendant as per policy conditions.The complaint was allowed.Chennai Ombudsman CentreCase No. IO (CHN) / 21.06.2080 / 2005 - 06Shri J. Anthoniesamy C. M. YagappaVs.Life Insurance Corporation of IndiaAward Dated 09.08.2005Shri J. Anthoniesamy Charles Marie Yagappa had taken a policy on the life of hisMaster. Richard Joseph Yagappa on 12.12.1996. The assured died on 05.01.2004. TheInsurer denied the death claim payment on the ground that the details regarding theassured’s pre-proposal illness of congenital heart disease and the treatment availed forthe same was not disclosed in the proposal form.On 28.07.2005 a personal hearing of both the parties was held. The Complainant,during the course of the hearing said that he was not knowing English and the proposalform was filled in by the agent who was known to the family for long. He also admittedthat his son had undergone open-heart surgeries successfully in the years 1994 and1997. The Insurer argued that the details of pre-proposal treatment at Madras MissionHospital was not disclosed in the proposal form. They could produce evidence, such asDischarge Summary of the same hospital, issued in December, 1994 at 7 months ofage as well as the subsequent treatment in 1997, in support of their argument that theassured has suffered from congenital heart problem and the treatment that followed tillthe death.After hearing both the parties, the Ombudsman observed that there was substance inthe contentions of the Insurer of fraudulent material suppression by the proposer, andheld the repudiation legally and factually tenable.The Complaint was dismissed.Chennai Ombudsman CentreCase No. IO (CHN) / 21.08.2082 / 2005 - 06Smt. SoundariVs.Life Insurance Corporation of India
Page 1 and 2: Death ClaimAhmedabad Ombudsman Cent
Page 3 and 4: Ahmedabad Ombudsman CentreCase No.
Page 5 and 6: proposal. Respondent submitted a ce
Page 7 and 8: 08.01.04. The recorded cause of dea
Page 9 and 10: Award Dated 05.05.2005Happened that
Page 11 and 12: the Assured housing loan borrower d
Page 13 and 14: COUNTERED by LIC that claim in resp
Page 15 and 16: Case No. LIC / 450 / Jalandhar / Ga
Page 17 and 18: Vs.Life Insurance Corporation of In
Page 19 and 20: the revival null and void. The Insu
Page 21 and 22: as reported in AIR 1981 MP 69 (DB)
Page 23 and 24: grant insurance to female lives wit
Page 25 and 26: there was suppression of informatio
Page 27 and 28: stated in the certificate in reply
Page 29 and 30: Smt. G. Saroja, lodged a complaint
Page 31 and 32: From the evidences submitted it was
Page 33 and 34: taken treatment for the same thus m
Page 35: On 24.06.2005, a personal hearing o
Page 39 and 40: incumbent upon the Insurer to prove
Page 41 and 42: particulars in the proposal form co
Page 43 and 44: proposal treatment and the surgery
Page 45 and 46: Award Dated 14.09.2005Mr. M. G. Mug
Page 47 and 48: Chennai Ombudsman CentreCase No. IO
Page 49 and 50: policy. The Insurer argued that the
Page 51 and 52: post-mortem report his age at that
Page 53 and 54: Hon’ble Insurance Ombudsman today
Page 55 and 56: As the life assured was reported to
Page 57 and 58: to have been under treatment for tu
Page 59 and 60: It was also alleged by the LIC that
Page 61 and 62: died on 03.01.2004. The cause of de
Page 63 and 64: Life Insurance Corporation of India
Page 65 and 66: Although the complainant disputed t
Page 67 and 68: assured to be guilty of deliberate
Page 69 and 70: The life assured was also medically
Page 71 and 72: for the reasons as aforesaid, the r
Page 73 and 74: FACTS OF THE CASEOne Shri T. Nagara
Page 75 and 76: In the above facts, I am of the vie
Page 77 and 78: One Shri Devraj, S/o Shri T. Bosagi
Page 79 and 80: death was reported to be gangrene r
Page 81 and 82: Vs.Life Insurance Corporation of In
Page 83 and 84: ombudsman asked the insurer to re-o
Page 85 and 86: Zonal Review Committee as well as t
Page 87 and 88:
However, the claimant was advised t
Page 89 and 90:
There is conclusive evidence throug
Page 91 and 92:
On analysis of the facts as present
Page 93 and 94:
The policy was issued on the basis
Page 95 and 96:
second week of November, 2001 durin
Page 97 and 98:
The entire records have been scruti
Page 99 and 100:
On an analysis it is observed that
Page 101 and 102:
cough and fever and on 06.01.2003 f
Page 103 and 104:
From the investigation Report it is
Page 105 and 106:
22.12.95 at Bombay hospital. Howeve
Page 107 and 108:
unfortunately expired on 18.12.2003
Page 109 and 110:
Shukla approached the Office of the
Page 111 and 112:
Award Dated 26.09.2005Shri Ramesh H
Page 113:
The relevant records submitted to t
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Death Claim - Gbic.co.in

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