Death Claim - Gbic.co.in

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Smt. K. M. ShahVsLife Insurance Corporation of IndiaAward Dated 21.07.2005The complaint relates to the deduction made from Death Claim proceeds of VarishthaPension Policy. LIC had issued instruction that not more than one Policy can be issuedto a person. But this was not done at the outset i.e. with launching of the Plan but itwas done after few months. Before such instructions were issued a policyholder tooktwo separate Policies. Annuity payment started in both the Policies as promised. ThePolicyholder died 8 months after start of the annuity. The return of Premium paidbecomes payable subject to deduction of any annuity payable and paid after date ofdeath. But the Respondent recovered the entire amount of all annuity instalment paidunder the second Policy. According to them Policyholder was not eligible to obtainsecond Policy. It was held that Respondent cannot apply the instructions withretrospective effect and therefore any Policies issued prior to restrictive instructionsshould be eligible to earn annuity. So, recovery was not justified and Respondent wasdirected the said amouunt with 8 % interest.Ahmedabad Ombudsman CentreCase No. 21 - 001 - 0362Mrs. Wisonta Hanokh ParmarVsLife Insurance Corporation of IndiaAward Dated 22.07.2005The Deceased Life Assured had proposed the insurance on 12.03.2002. FPR wasissued on 18.04.2002 with Risk commencing on 28.03.2002. Death occurred on5.12.2003 by Cancer of Stomach. Respondent pleaded that certificate of Treatmentfrom Dr. Ronak Shah mentioned that the DLA had consulted Dr. Shah on 16.01.2001for Chest Pain evidently earlier than 12.03.2002 i.e. date of Proposal. It was also notedthat the DLA had been examined by Dr. R. L. Kothari on 01.04.2002 in OPD forEpigastric Mild Pain. This illness existed since 1 ½ month before 01.04.2002 whencalculated back. The Respondent argued that despite there being past history of illnessof abdominal pain treated by Doctors, the specific questions in the proposal form werereplied in negative by the DLA. This correct information was withhold by the DLA.Against this the Complainant pleaded that he had disclosed information of UlcerOperation done in 1971, and chest - pain and epigastric pain was due to normalacidities in the stomach it was held that the suppressed facts regarding history of painin abdomen had nexus with cause of death due to Cancer. The Suppression wasmaterial and intentional. The treatment taken during date of proposal and date of FPRis also not informed to the Respondent. So the complaint fails to succeed and theRespondent’s decision to repudiate Claim is upheld.Ahmedabad Ombudsman CentreCase No. 21 - 001 - 0011K. B. ZalaVsLife Insurance Corporation of IndiaAward Dated 27.07.2005Death Claim under a Life policy was repudiated on the ground of non-disclosure ofmaterial facts by making incorrect statements regarding his while filling up the
proposal. Respondent submitted a certificate of treatment from Dr. Milan Dave. It interalia stated that the DLA was his patient on OPD basis whom he had examined ondifferent dates from 31.05.2000. Dr. Dave indicated the DLA to be carrying history ofcough, fever, breathlessness and the DLA was diagnosed by him as suffering fromAllergic Bronchial Asthma. It was also mentioned in Certificate that patient wassuffering “off and on since long time” and the history of the ailment was provided by“patient himself to Dr. Dave”. The DLA did not mention anything about the aboveailment and treatment taken by him in the Proposal form. This information was materialfor taking underwriting decision of the high risk Policy by the DLA. Also the repudiationwas done within 2 years and therefore the case did not get the protections of theennobling provisions under Section 45 of Insurance Act 1938. Complaint failed tosucceed.Ahmedabad Ombudsman CentreCase No. 21 - 001 - 0112P. M. PrajapatiVsLife Insurance Corporation of IndiaAward Dated 29.07.2005Repudiation of Deah Claim on the ground tha DLA did not inform about the treatmenttaken by him after submission of proposal paper but before date of Acceptance letter.The Respondent pleaded that this was breach of terms and Conditons on which theRisk was accepted. The DLA had taken treatment for burning sensation duringurination suspected to be urinary tract infection and crystallurea by treating doctor. TheRenal function test and urine analysis disclosed absolute normalcy. Only Antibiotictreatment was taken for 5 days and his condition was certified to be good. The tratingdoctor had never treated him ever before. The DLA was medically examined at theproposal stage and Risk was accepted after scrutiny of special reports. The DLA diedof drowning. There was no nexus between the alleged non-disclosure of the treatmenttaken during submission of proposal and date of Acceptance letter-cum-First Premiumreceipt. The repudiation was set aside and Respondent were directed to pay the Claimbased on following consideration.1. The Claim is free from any other infirmity like suppression of material facts inProposal.2. The underwriting of the Proposal amply demonstrates the screening of medicaland moral hazard of the Proposer before acceptance.3. While it is true that there was medical consultation on 24.04.2004, the RenalFunction Test and Urine Analysis show normal result.4. There had been thus only a formal lack of non-compliance on the part of the DLAto the Condition stated in the FPR.5. Death was Accidental having obviously no nexus whatsoever with the allegednon-communicated medical consultation.Ahmedabad Ombudsman CentreCase No. 21 - 001 - 0067D. P. PatelVsLife Insurance Corporation of IndiaAward Dated 29.07.2005
Page 1 and 2: Death ClaimAhmedabad Ombudsman Cent
Page 3: Ahmedabad Ombudsman CentreCase No.
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 and 36: On 24.06.2005, a personal hearing o
Page 37 and 38: A hearing of both the Insurer and t
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
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As the life assured was reported to
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to have been under treatment for tu
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It was also alleged by the LIC that
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died on 03.01.2004. The cause of de
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Life Insurance Corporation of India
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Although the complainant disputed t
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assured to be guilty of deliberate
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The life assured was also medically
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for the reasons as aforesaid, the r
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FACTS OF THE CASEOne Shri T. Nagara
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In the above facts, I am of the vie
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One Shri Devraj, S/o Shri T. Bosagi
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death was reported to be gangrene r
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Vs.Life Insurance Corporation of In
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ombudsman asked the insurer to re-o
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Zonal Review Committee as well as t
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However, the claimant was advised t
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There is conclusive evidence throug
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On analysis of the facts as present
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The policy was issued on the basis
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second week of November, 2001 durin
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The entire records have been scruti
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On an analysis it is observed that
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cough and fever and on 06.01.2003 f
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From the investigation Report it is
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22.12.95 at Bombay hospital. Howeve
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unfortunately expired on 18.12.2003
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Shukla approached the Office of the
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Award Dated 26.09.2005Shri Ramesh H
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The relevant records submitted to t
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