Microsoft Word - Death Claim

Death Claim

Ahmedabad Ombudsman Centre

Case No. 21 - 001 - 0371

Vaishali B. Shah

Life Insurance Corporation of India

Award Dated 06.10.2005

Complainant’s Husband had three LIC Policies. First Policy commenced on 28-2-2002

for S. A of Rs. 1,00,000/-. The other 2 Policies commenced on 25-3-2003 for S. A of

Rs. 1,00,000/- each. He died in March 2004. Respondent settled the Claim under first

Policy, but repudiated the other two Claims. Respondent submitted that the DLA did

not disclose in the Proposal Form, the fact of his earlier Policy which was in force,

thereby the Proposals were accepted without Special Medical Reports like ECG since

the S. A was exceeding Rs, 2,00,000/-. Documents and submissions perused. It is

observed that the suppressed particulars about the previous Insurance was material for

underwriting process, and the fact of the first Policy, if disclosed in the Proposal, the

Respondent would have called for Special Medical Reports of the DLA as the S. A was

exceeding Rs, 2,00,000/- for a Proposer having Age at Entry between 36 and 50 years.

Repudiation upheld.

Ahmedabad Ombudsman Centre

Case No. 14 - 014 - 0178

RL Parmar

Aviva Life Insurance Corporation of India

Award Dated 14.10.2005

Death claim under life insurance Policy was repudiated for non compliance of

documents like First information Report, Final Police Inquest Report and Discharge

Summary alongwith hospitalization records. Again it was a case of death due to burn

due to Kerosene and it occurred during first year of the Policy wherein suicide Clause

is operative. Without help of the above referred documents the Insurer could not decide

the admissibility of the claim and hence the repudiation was upheld.

Ahmedabad Ombudsman Centre

Case No. 21 - 001 - 0003

B. B. Vasava

Life Insurance Corporation of India

Award Dated 25.10.2005

Death Claim under a Life Insurance Policy was repudiated on the ground of

suppression of material fact. The DLA had taken treatment for Chronic Alcoholic

Disease, Cirrhosis of Liver prior to date of Proposal. He had not mentioned this fact

while replying relevant questions regarding history of personal health. Again it was

contended by the Respondent that this suppression of fact was very vital and adversely

affected the Respondent’s decision to accept the risk. Suppression of material fact

established. Repudiation upheld.

Ahmedabad Ombudsman Centre

Case No. 21 - 001 - 0147

RN Shah

Life Insurance Corporation of India

Award Dated 31.10.2005

Death claim under life Policy was repudiated on the ground of suppression of material

fact. The deceased life Assured did not mention his personal history of skin lesion and

morphea (skin changes) at the Proposal stage. Later he died due to Multiple

Myelomea. Certificate of treatment mentioned that the DLA was suffering from Morphea

since 1995 whereas the Policy incepted in 2004. The suppression of material fact could

be esablished by the Respondent and repudiation was upheld.

Ahmedabad Ombudsman Centre

Case No. 21 - 007 - 0417

A. M. Garange

Max Newyork Life Insurance Corporation of India

Award Dated 31.10.2005

Death Claim under life Policy was repudiated on the ground of suppression of material

fact. It was alleged by the Respondent that the DLA had suppressed the facts

regarding his regular alcohol consumption. The Respondent could not collect positive

evidence to prove the above allegation. The investigation made by the Respondent

contained only presumtions and no concrete evidence. Repudiation set aside and

Respondent was directed to pay

Rs. 3/- lacs.

Ahmedabad Ombudsman Centre

Case No. 21 - 001 - 0139

LS Tiwari

Life Insurance Corporation of India

Award Dated 21.11.2005

Death Claim under three life insurance Policies repudiated on the ground of

suppression of material fact.

Policy No. 834088314 : Personal statement submitted at the time of submitting

proposal on 10.1.2003 was incorrectly answered by the DLA. But the histopathology

report dt. 1.2.2003 revealed the ailment of Cancer. There is no proof establishing

existence of disease prior to this date. So the suppression is not established and.

Repudiation is set aside. The Respondent is directed to pay Rs. 56,050/-.

Policy Nos.834040240 & 834041180 : Both these Policies were revived on the basis of

Declaration of Good Health dtd. 31.3.2003. Here the revelation of Histopathology

Report dtd. 1.2.2003 preceded the revival of the Policy. So the repudiation since

revival is upheld.

Ahmedabad Ombudsman Centre

Case No. 21 - 001 - 0239

Smt. Bhikuben Raiyabhai Rala

Life Insurance Corporation of India

Award Dated 22.11.2005

Life Insurance Claim Repudiated - The Complainant had lodged a Claim on death of

her husband. The Claim was repudiated since the Respondent claimed having proof

that the deceased was suffering from Dialysis for two years before commencement of

the Policy. The Document solely relied by the Respondent was a Medical Attendant’s

Certificate where the deceased breathed his last. Since no evidence of treatment could

be submitted, the repudiation of the Claim was set aside and the Respondent was

directed to pay the full Claim amount.

Ahmedabad Ombudsman Centre

Case No. 21 - 001 - 0372

Shri Mukeshbhai D. Makwana

Life Insurance Corporation of India

Award Dated 28.11.2005

Life Insurance Claim Repudiated - The Complainant had lodged a Claim on death of his

wife. The Claim was repudiated by application of Clause 4(B) on Female Lives which

provides for refund of premium in case of death due to an accident other than in a

public place. According to the Panchanama, the death took place by a fire accident

inside the deceased’s house and not in a Public Place. As such, the repudiation of the

Claim was upheld with no relief to the Complainant.

Ahmedabad Ombudsman Centre

Case No. 21 - 001 - 0114

Smt. Muktaben M. Kahagara

Life Insurance Corporation of India

Award Dated 28.11.2005

Life Insurance Claim Repudiated - The Complainant had lodged a claim on the death of

her husband. The claim was repudiated by the Respondent on grounds of non

disclosure of the fact that the deceased was a known case of Diabetes Mellitus for the

last 4 years and that a Medical Certificate was also on record to confirm the treatment.

The Deceased Life Assured was a Graduate in Government Service. It is reasonable to

hold that the deceased was knowing of his ailments and had suppressed material facts.

As a result, the repudiation of the subject claim was upheld with no relief to the

Complainant.

Ahmedabad Ombudsman Centre

Case No. 21 - 001 - 0172

Smt. Bhavnaben P. Rajyaguru

Life Insurance Corporation of India

Award Dated 28.11.2005

Life Insurance Claim Repudiated - The Complainant had lodged a claim on the death of

her husband. The claim was repudiated by the Respondent on grounds of non

disclosure of the fact that the deceased was suffering from pain and swelling of left

cheek region and had habit of pan masala chewing as well as cigarette smoking for the

last 25 years. Documents from Doctor and Cancer Hospital were relied to. This

addiction had a very close nexus with Buccal Mucos which caused the death of the

deceased. As a result, the Repudiation of the subject claim was upheld with no relief to

the Complainant.

Ahmedabad Ombudsman Centre

Case No. 21 - 001 - 0149

Shri Rekhaben A. Nathani

Life Insurance Corporation of India

Award Dated 28.11.2005

Life Insurance Claim Repudiated - The Complainant had lodged a claim on the death of

her husband. The claim was repudiated by the Respondent on grounds of non

disclosure of the fact that the deceased was suffering from Anaemia, HIV Positive prior

to the date of the Proposal. The Documents relied by the Respondent was Certificate

of Treatment from three Medical Examiners. Since no evidence of treatment could be

submitted, the repudiation of the Claim was set aside and the Respondent was directed

to pay the full Claim amount.

Ahmedabad Ombudsman Centre

Case No. 21 - 009 - 0151

Mr. Amarsingh S. Thakor

Bajaj Allianz Life Insurance Corporation Ltd.

Award Dated 26.12.2005

Repudiation of Death Claim since it could be proved that the Age of the Proposer at

entry exceeded that declared by over 15 years. The Respondent had during the course

of investigation found that the Age of the Proposer from the Ration Card exceeded by

over 15 years. The Age of the Proposer as shown in the Ration Card too was relatively

with Ages of other family members. As per the Rules of the Respondent Insurer,

maximum Age at entry with a Non-Standard Age Proof would be 50 yrs. The

misrepresentation of Age imposed higher premium and even in declining the risk. As

such pleaded that the Complainant’s husband had violated the Curfew norms and died

while being part of a mob engaged in attacking individuals of a Minority Community.

The Respondent repudiated the Claim on the ground that the Insured had committed

Breach of Law with Criminal intent. It was observed that the name of the deceased

appeared in the Chargesheet as a “Victim”. The Final Police Report too did not contain

any indication in the nature of indictment of the deceased. Since there was no

indisputabe evidence to invoke “Breach of Law with Criminal Intention”, the benefit of

such doubt is to be extended to the Claimant only and as such the decision of the

Respondent to repudiate the Claim was upheld with no relief to the Complainant.

Ahmedabad Ombudsman Centre

Case No. 11 - 004 - 0063

Mr. Haribhai S. Patel

Life Insurance Corporation of India

Award Dated 26.12.2005

Repudiation of Death Claim in an unconcluded contract : The proposal on the life of the

Complainant’s sister was registered and the deposit of first premium was received.

Since, the proposer was a Single Lady, additional requirements were called for in

writing to obtain details of LIC policies on the life of her family members before

accepting the risk. In the meanwhile, the proponent died. However, since the risk had

not been accepted and no underwriting decision was communicated to the Proponent,

the decision of the Respondent to consider the case as one of an unconcluded contract

was upheld and the Respondent was directed to refund the deposit of first premium

only.

Ahmedabad Ombudsman Centre

Case No. 21 - 001 - 0211

Smt. M. K. Machhrekar

Life Insurance Corporation of India

Award Dated 29.12.2005

Repudiation of Death Claim on the grounds that the Life Assured was alcoholic and

that this fact was not disclosed while taking the Insurance Policy. This fact was

revealed in a statement obtained by a Claim Consultant who mentioned that the

Deceased “only occasionally took a peg of Alcohol, but did not have its habit or

addiction”. The report of the in - house investigator or the External investigator did not

categorically recommend repudiation. As such repudiation was set aside and the

Respondent was directed to pay the full claim.

Ahmedabad Ombudsman Centre

Case No. 21 - 011 - 0110

Mr. Mahipalsingh Jain

Bajaj Allianz Life Insurance Co. Ltd.

Award Dated 30.12.2005

Repudiation of Death Claim on the grounds of non disclosure while taking the

Insurance Policy. The Treatment papers of the consultation taken by the deceased

prior to the date of proposal noted of Hypertension, Easy fatigability, Head Ache, Chest

discomfort etc. This fact was not revealed while filling in the proposal form for

insurance. Since the consultations were taken for a long period of time and since

revealing these disease would have called for the Insurer calling for additional health

reports, it was concluded that the non-disclosed facts were material and hence the

decision of the Respondent to repudiate the subject Claim was upheld with no relief to

the Complainant.

Ahmedabad Ombudsman Centre

Case No. 21 - 001 - 0396

Smt. Kavita S. Raghani

Life Insurance Corporation of India

Award Dated 9.1.2006

Repudiation of a Life Insurance Policy : The husband of the Complainant had withheld

material facts while filling up the Proposal Form for Insurance that he had taken Leave

on Sickness grounds for IHD + HT + Bronchial Asthma. Since non disclosure of the

above sickness had an impact on the appraisal of the Risk and Underwriting decision

of the Respondent as per their framed rules, materiality of the undisclosed information

is established. Besides the deceased life assured was hinself a qualified Medical

Practitioner. Hence the decision of the Respondent to repudiate the claim was upheld

with no relief to the Complainant.

Ahmedabad Ombudsman Centre

Case No. 21 - 001 - 0227

Smt. Shardaben S. Gupta

Life Insurance Corporation of India

Award Dated 9.1.2006

Repudiation of Life Insurance Policy on the ground of suppression of material facts.

Proposal for Insurance submitted in April 2002 and the Deceasd died in November

2004. Records showed two Certificates of Hospital Treatment which recorded history of

the deceased’s illness of Convulging disorder, Wilson’s disase, Cirrhosis of Liver since

six years (i.e. well before the date of the Proposal) Had these facts been disclosed,

specialised tests etc and / or extra premiums would have warranted thecase. Besides,

deceased was a distributor of Medicines and was holding Diploma in Pharmacology and

was expected to know his physical condition and health history along with its

implications. Hence, it became established that withhold of material facts was

deliberately committed with a malafide motive. As such the decision of the Respondent

to repudiate the Claim was upheld with no relief to the Complainant.

Ahmedabad Ombudsman Centre

Case No. 21 - 001 - 0244

Smt. Manuulaben S. Vora

Life Insurance Corporation of India

Award Dated 19.1.2006

Repudiation of Death Claim. The Respondent could prove from a letter of the treating

Doctor that the Complainant was being treated for Pulmonary TB and that the same

was not mentioned in the proposal for insurance. The non-disclosure being a material

fact, the decision of the Respondent to repudiate the subject Claim was upheld with no

relief to the Complainant.

Ahmedabad Ombudsman Centre

Case No. 21 - 001 - 0155

Smt. Asha H. Pai

Life Insurance Corporation of India

Award Dated 3.2.2006

Repudiation of a Double Accident Benefit under a Life Insurance Policy : Even though

the Deceased had Life Insurance policies of Rs. 75,000/- on which Double Accident

Benefit Claim was repudiated by the Respondent, it was observed that the Deceased

had vide Case No 11-004-0241 complained on repudiation of PA Claim by a Non-Life

Insurer for a Sum Insured of Rs. 23.00 lacs. Thus since the total amount comes to Rs.

23.75 lacs, as per Rule 16(2) of the RPG Rules, no award was granted.

Ahmedabad Ombudsman Centre

Case No. 21 - 001 - 0247

Smt. Varshaben K. Chaliawala

Life Insurance Corporation of India

Award Dated 20.2.2006

Repudiation of Claim under Life Insurance Policy on the ground of suppression of

Medical Facts by the DLA at the time of revival of the Lapsed Policies. The DLA had

suppressed history of Hypertension for 4 to 5 years while filling up the Declaration of

Good Health form for revival of the policy. Citing a case adjudicated by the National

Commission, which stated that the incorrect information of personal health in the

Personal Statement of Health for revival of Lapsed policies vitiated the resulting revival

of the contract and that such cases are not covered under Sec. 45 of the Insurance

Act, the decision of the Respondent to repudiate the subject claim was upheld with no

relief to the Complainant.

Ahmedabad Ombudsman Centre

Case No. 21 - 001 - 0068

Smt. Bhartiben D. Mistry

Life Insurance Corporation of India

Award Dated 20.2.2006

Repudiation of Death Claim under Life Insurance Policy : The Complainant’s husband

died within 14 months of taking a policy due to ARDS with Septicemia on being

operated for Transposition of brain vessels with large intracerebral abcess. Claim for

the Life Insurance Policy was repudiated on the grounds of misstatement and

withholding of material information regarding health. The papers on hand showed that

the deceased was operated in a Hospital for Valves prior to taking the policy which was

not informed in the proposal form. The operation being a major one for congenital heart

disease and the fact that the duration of the policy fell short of the period stipulated

under Sec. 45 of the Insurance Act, 1938; the decision of the Respondent Insurer to

repudiate the subject Claim was upheld.

Ahmedabad Ombudsman Centre

Case No. 21 - 001 - 0226

Smt. Bharati Mahesh Mehta

Life Insurance Corporation of India

Award Dated 24.2.2006

Repudiation of Claim under Life Insurance Policy : It was observed that the deceased

Life Assured was treated in Hospitals of repute for pain in abdomen, peri-umblical and

epigastric pain etc prior to the date of the Proposal for Insurance and the same was not

disclosed therein. He expired within 7 months of taking the policy. As per the

Underwriting rules of the Respondent Insurer, the subject disclosure would have

required special tests resulting into acceptance of the Risk with restrictions. As such,

the decision of the Respondent to repudiate the subject Claim was upheld with no relief

to the Complainant.

Ahmedabad Ombudsman Centre

Case No. 24 - 001 - 0056

Mr. Jaydeep N. Chavda

Life Insurance Corporation of India

Award Dated 27.3.2006

Repudiation of death Claim. While taking the policy, the fact of the Life Assured having

diabetes was not mentioned in the Proposal form. The Respondent during the course of

the hearing, submitted a copy of a Doctor’s Certificate which confirmed that the

deceased was a known case of diabetes besides suffering from severe general

weakness and tremor. There were Certificates from other treating Doctors as well

confirming to the same. Besides, the employer too confirmed Medical Leave taken by

the deceased which was suppressed in the proposal form. Since non disclosure of

Diabetes is a suppression of material facts, the Repudiation of the Claim was upheld

with no relief to the Complainant.

Ahmedabad Ombudsman Centre

Case No. 21 - 001 - 0180

Smt. Anusuyaben S. Bhalani

Life Insurance Corporation of India

Award Dated 27.3.2006

Repudiation of Death Claim : While taking the policy, the fact of the Life Assured

having diabetes was not mentioned in the Proposal form. The Respondent during the

course of the hearing, submitted a copy of a Doctor’s Certificate which confirmed that

the deceased was suffering from several disease including diabetes for nearly a month

before proposing for Insurance. Several pathological reports etc. also confirmed

Diabetes Type II. Since non disclosure of Diabetes is a suppression of material facts,

the Repudiation of the Claim was upheld with no relief to the Complainant.

Bhopal Ombudsman Centre

Case No. LI - 460 - 21 / 07 - 06 / STN

Smt. Anita Chaturvedi

Life Insurance Corporation of India

Award Dated 30.11.2005

Smt. Anita Chaturvedi, Complainant is the wife of late Shri Kailashnath Chaturvedi,

DLA. DLA had a life insurance policy numbered 376310351 with the Respondent. The

Complainant has complained that when the DLA died, death claim was preferred with

the Respondent but the same was repudiated on the grounds of suppression of

previous policy no. 376309779 and also due to the fact that he was suffering from

chest pain at the time of proposal, which was suppressed by DLA. The claimant

preferred a complaint to this Office.

Observations of Ombudsman : I have gone through the materials on records and

submissions made during hearing and my observations are summarized as follows:

Respondent stated that the complainant submitted a death certificate dated 09.08.2004

wherein it is mentioned that death occurred at Uparhati, Rewa and accordingly the

claim under previous policy no. 376309779 was paid for 4 lacs. Subsequently, the

complainant submitted another death certificate dated 19.08.2004 for claim under

policy no. 376310551 wherein it was mentioned that death occurred at SGMH, Rewa. In

claim form B, it is mentioned that the DLA was suffering from chest pain and he died on

03.08.2004 due to heart attack.

Complainant stated that since DLA has not received previous policy of 4 lacs from the

Respondent, he did not disclose the details of the said policy in the proposal of the

policy in question. Complainant also stated that the agent had filled in the proposal

form and the DLA was not aware of the replies given in the proposal form.

It is also observed that DLA has taken a policy of 4 lacs on 14.07.2004 and while

taking the policy no. 376309779 on 26.07.2004, DLA was sick and was suffering from

chest pain and has also not disclosed about having taken another policy of 4 lacs just

12 days prior to this policy.

Insurance is a contract of Utmost Good Faith where parties are required to disclose all

the material information. In the instant case DLA willfully suppressed the information of

previous policy.

In view of the circumstances stated above, I am of the considered opinion that the

decision of the Respondent to repudiate the claim on this ground is fair and justified. I

found no reason to interfere with the decision taken by the Respondent. Hence the

complaint is dismissed without any relief.

Bhopal Ombudsman Centre

Case No. LI - 463 - 24 / 07 - 06 / IND

Shri Ram Kumar Bairagi

Life Insurance Corporation of India

Award Dated 07.12.2005

Shri Ram Kumar Bairagi, Complainant is the father of late Shri Purushottam Bairagi,

DLA. DLA took life insurance policies numbered 341060268, 341060293, 341063412,

341066484, 341066808 & 341066214 from the Respondent. DLA died and the claim

was preferred by the Complainant with the Respondent but the same was delayed. The

claimant preferred a complaint to this Office.

Observations of Ombudsman : I have gone through the materials on records and

submissions made during hearing and my observations are summarized as follows:

The Respondent stated that they have settled death claim under Policy numbers, viz.,

341060268, 341060293 & 341063612. Further Respondent stated that regarding policy

numbers, viz., 341066214, 341066808 & 341066484, DLA committed suicide within one

year of insurance. Since suicide clause is applicable under the above policies, no

death claim is payable.

It is observed from records that the Respondent has paid death claim under policy

numbers, viz., 341060268, 341060293 & 341063612 to the nominee of DLA.

It is very clear that the cause of death of DLA was suicide, which was admitted by the

Complainant, hence as per policy conditions regarding suicide clause, nothing is

payable under the policies numbered 341066214, 341066808 & 341066484.

In view of the circumstances stated above, the decision of the Respondent to repudiate

the death claim under policy numbers 341066214, 341066808 & 341066484 and to

settle the claim under the remaining three policies is fair and justified. I found no

reason to interfere with the decision taken by the Respondent.

Bhopal Ombudsman Centre

Case No. LI - 524 - 21 / 08 - 06 / IND

Smt. Bhawaridevi Vaishnav

Life Insurance Corporation of India

Award Dated 28.12.2005

Smt. Bhawaridevi Vaishnav, complainant is the wife of Late Shri Daulatram

Prabhudayal Vaishnav, DLA. DLA had a life insurance policy numbered 342622385

taken on 28.03.2002. The DLA died due to heart attack on 28.02.2004. When the

complainant approached the Respondent for death claim, the same was repudiated on

the ground of suppression of material facts regarding health of DLA in the Proposal

form of policy in question. Subsequently, the Complainant had referred the case to

Respondent’s claim review committee for reconsideration, which was also upheld by

them. The claimant preferred a complaint to this Office.

Observations of Ombudsman : I have gone through the materials on records and

submissions made during hearing and my observations are summarized as follows:

The Complainant contended that her husband (DLA) was not suffering from any

disease prior to his death and no treatment was taken by him.

The Respondent informed that the DLA was admitted in Jawaharlal Nehru Hospital,

Ajmer for acute Posterior Lateral Myocardial Infarction prior to taking the policy which

was concealed by him in the proposal form of the policy in question.

It is observed from hospital records dated 28.02.2004 that DLA was a known patient of

Acute Posterior Lateral Myocardial Infarction and was admitted in the hospital on

28.02.2004 for the said ailment whereas the proposal form dated 19.03.2002 signed by

DLA shows that he was keeping normal health at the time of taking policy. It is also

observed from claim forms B & B1 that the DLA died due to IHD & MI and also had a

similar episode of attack two years back.

Insurance is a contract of Utmost Good Faith where both the parties are required to

disclose all the material facts. In the present case, DLA has given incorrect statement

regarding his health to mislead the Respondent to accept his proposal on his life. Had

the DLA disclosed his past illness, it would have certainly affected the Respondent’s

underwriting decision.

In view of the circumstances stated above, I am of the considered opinion that the

decision of the Respondent to repudiate the claim on this ground is fair and justified. I

found no reason to interfere with the decision taken by the Respondent. Hence the

complaint is dismissed without any relief.

Bhopal Ombudsman Centre

Case No. LI - 538 - 24 / 09 - 06 / IND

Shri Kamlendu Gandharv

Life Insurance Corporation of India

Award Dated 30.11.2005

Shri Kamlendu Gandharv, Complainant is the son of Late Shri Biharilal Gandharv, DLA.

DLA had taken a life insurance policy numbered 3427332514 on 28.01.2002 under

Table/Term: 14/20 for Sum Assured of Rs. 50000/- from the Respondent. The DLA died

due to Cardio Respiratory arrest on 13.03.2004 and the claim was preferred by the

Complainant with the Respondent. But the claim was repudiated by the Respondent on

the grounds of wrong information given regarding age by DLA in the Proposal form of

the policy in question. The claimant preferred a complaint to this Office.

Observations of Ombudsman : I have gone through the materials on records and

submissions made during hearing and my observations are summarized as follows:

The complainant had submitted two certificates one in respect of identity card dated

17.06.95, which shows that his age as on 01.01.1995 is 50 years i.e. as on 28.01.2002

(on the date of taking the policy) his age is 57 years. In another certificate i.e. voter

list of 2000 his age is 54 yrs. i.e., as on 28.01.2002 (on the date of taking the policy)

his age is 56 yrs.

Respondent stated that the age of DLA varies from all the three separate documents,

i.e. as per voter list 2000 age is 56 yrs. , records of Govt. Hospital Mandsaur is 70 yrs,

and date of birth as per copy of school certificate is 01.11.53. Since there is a vast

difference in actual age and the age mentioned in the proposal form, investigation was

carried out and it was found that the certificate submitted by the Complainant belongs

to Shri Nathulal whereas the name of DLA is Biharilal.

It is observed from the investigation report of the Respondent that the DLA has not

submitted the correct age proof while submitting the proposal. During hearing, the

complainant submitted the age proof of DLA which shows that at the time of taking

policy, his age was about 57 years while DLA showed his age as 48 years in the

proposal of the policy in question. Hence it is proved that the DLA has submitted a

forged age proof to mislead the Respondent to accept his proposal on his life. Had the

DLA disclosed his correct age, he would not have been granted insurance under

Endowment plan for the terms of 24 years.

In view of the circumstances stated above, I am of the considered opinion that the

decision of the Respondent to repudiate the claim on this ground is fair and justified. I

found no reason to interfere with the decision taken by the Respondent. Hence the

complaint is dismissed without any relief.

Bhopal Ombudsman Centre

Case No. LI - 555 - 21 / 09 - 06 / IND

Shri Ramkumar Kashyap

Life Insurance Corporation of India

Award Dated 28.11.2005

Shri Ramkumar Kashyap, Complainant is the brother of Late Shri Indorilal Kashyap,

DLA. DLA took a life insurance Policy numbered 344141957 from the Respondent. The

DLA died due to Jaundice on 22.07.2004. The Policy had run for only 4 months. When

the complainant preferred death claim with the Respondent, the same was repudiated

on the grounds of suppression of material facts regarding health of DLA in the Proposal

form. Subsequently, the Complainant had referred the case to Respondent’s claim

review committee for reconsideration, which was also upheld by them. The claimant

preferred a complaint to this Office.

Observations of Ombudsman : I have gone through the materials on records and

submissions made during hearing and my observations are summarized as follows:

The Respondent contended that the DLA was admitted in M/s. Shree Indore Cloth

Market Hospital, Indore for urinary bound problem, abdominal pain and vomiting where

he was diagnosed of Jaundice on 10.02.2004 prior to taking policy, which was

concealed by him in the proposal form of the policy in question. Hence the claim was

repudiated.

It is observed from hospital records that the DLA was a known patient of

DM/COPD/Jaundice and was admitted in the hospital from 07.02.2004 to 12.02.2004

for urinary bound problem whereas the proposal form signed by DLA shows that he was

keeping normal health at the time of taking policy.

It is also observed from claim forms B & B1 that the DLA died of Jaundice. In the

present case, there is sufficient evidential proof to show that the DLA was already

suffering from serious ailments but suppressed this in the proposal form. Had the same

been brought to the knowledge of the Respondent, the underwriting decision would

have been different.

In view of the circumstances stated above, I am of the considered opinion that the

decision of the Respondent to repudiate the claim on this ground is fair and justified. I

found no reason to interfere with the decision taken by the Respondent. Hence the

complaint is dismissed without any relief.

Bhopal Ombudsman Centre

Case No. LI - 556 - 24 / 09 - 06 / BPL

Smt. Kiran Badgujar

Life Insurance Corporation of India

Award Dated 30.11.2005

Smt. Kiran Badujar, Complainant is the wife of DLA, Late Shri J.P. Badgujar. DLA had

two life insurance policies, viz., 28684868 and 28694551 with the Respondent. The

DLA died on 11.10.2003. The Complainant approached the Respondent for payment of

death claim. But the same was delayed by the Respondent due to the fact that the

Complainant had submitted death claim intimation to the Respondent without original

policy bonds and also the case was found to be suspicious due to the fact that the

maturity claim amount was already paid against policy no. 28694551 to Shri Jagat

Pratap Singh on 04.06.2005. The claimant preferred a complaint to this Office.

Observations of Ombudsman : I have gone through the materials on records and

submissions made during hearing and my observations are summarized as follows:

The complainant stated that the correct policy number is 28684851. She has further

added that the policy loan was taken under the said policy and original policy is lying

with the Respondent.

The Respondent informed that they have received the letter of complainant on

25.11.2005 regarding correct policy number. But it is found that the said policy number

is also not available in their policy master record. Further it is also not clear about the

quantum of loan amount taken from the policy and from which Branch of LIC.

In view of the same, Respondent is hereby directed to ascertain the factual position of

the correct policy number from the Complainant and from its other Branches and settle

the claim on merits within 31

Dec. 2005. If the Complainant is not satisfied with the

decision taken by the Respondent, the Complainant would be free to approach this

forum with a fresh complaint.

Bhopal Ombudsman Centre

Case No. LI - 561 - 21 / 09 - 06 / BPL

Smt. Rekha Morie

Life Insurance Corporation of India

Award Dated 06.01.2006

Smt. Rekha Morle, Complainant is the wife of late Shri Ram Prasad Morle, DLA. DLA

had life insurance policies numbered 350927990, 350921851 & 350934524 with

Accident Benefit with the Respondent. Somebody murdered DLA and he died on the

midnight of 07.07.2004. The complainant preferred death claim with the Respondent,

only basic sum assured was paid but the accident benefit claim was repudiated by the

Respondent as per policy condition no. 10(b)(1). The claimant preferred a complaint to

this Office.

Observations of Ombudsman : I have gone through the materials on records and

submissions made during hearing and my observations are summarized as follows:

The Complainant stated that the culprits who murdered DLA were arrested and the

court decided the case against the culprits. The Respondent stated that the cause of

death of DLA was due to shock and hemorrhage as a result of multiple stab injury to

the neck and that the DLA was under the influence of liquor at the time of incident.

The complainant and the Respondent were directed to submit the copy of decision of

the court within 15 days for our further action. The Respondent submitted copy of

judgement of case dated 05.04.2005.

It is observed from the copy of judgement that the charge of murder is established and

as per Dr. Smt. Neelam Shrivastav who has examined the body of the DLA the cause of

death was due to multiple stab injury on the neck and excessive bleeding. In doctor’s

report from Medico Legal Institute M.P., it is clearly opined that the death was due to

shock and hemorrhage as a result of multiple stab injury to the neck. It is nowhere

mentioned in any of the Medical reports that the death of DLA occurred due to

consumption of liquor. Hence the contention of Respondent is not tenable that the

death has been caused due to the influence of liquor.

In view of the above, it is held that the Respondent’s decision of repudiating the AB

claim is not just and fair and is directed to settle the AB claim under Policy numbers in

question.

Bhopal Ombudsman Centre

Case No. LI - 588 - 24 / 10 - 06 / GWL

Smt. Indra Devi Kandha

Life Insurance Corporation of India

Award Dated 31.01.2006

Smt. Indra Devi Kandha, Complainant is the wife of late Shri Hasmathram Kandha,

DLA. DLA took a life insurance policy numbered 201211195 from the Respondent. The

policy lapsed and the same was revived on 03.01.2000 on the basis of DGH. The DLA

died on 08.01.2000 due to heart attack and the death claim was preferred by the

Complainant with the Respondent. But the payment was delayed. The claimant

preferred a complaint to this Office.

Observations of Ombudsman : I have gone through the materials on records and

submissions made during hearing and my observations are summarized as follows:

It is observed from records that the claim was not settled by the Respondent due to

dual reason that the signature of DLA differs in DGH for revival but have not submitted

any evidence for the same and also death certificate was prepared after 9 months of

death of DLA.

On scrutiny, it is no doubt observed that the Date of Death of DLA is 08.01.2000 and

the death certificate is dated 22.09.2000. But there is no nexus found between the

cause of death of DLA and preparation of death certificate and also the Respondent

has failed to adduce any documentary proof to show that there was malafide intention

of DLA on any count at the time of reviving the policy.

Also, in its self-contained note it is reported by Respondent that the claim is still under

investigation due to the above said reasons. But there are no concrete reasons found

to accept the delay in settlement of claim by the Respondent even after a period of 2

years from submission of all papers by Complainant.

In view of the above, it stands that the Respondent’s decision of delaying the claim

payment under the policy is not tenable.

In view of the circumstances stated above, I am of the considered opinion that the

decision of the Respondent not to settle the claim on this ground is unfair and

unjustified. However, the Respondent is directed to decide the claim on merits within

15 days. If the complainant is not satisfied with the decision taken by the Respondent,

the complainant would be free to approach this forum with a fresh complaint.

The complaint is thus disposed off.

Bhopal Ombudsman Centre

Case No. LI - 598 - 21 / 10 - 06 / BPL

Smt. Ravinder Kaur Chawla

Life Insurance Corporation of India

Award Dated 30.12.2005

Smt. Ravinder Kaur Chawla, Complainant is the wife of late Shri Satnam Singh Chawla,

DLA. DLA had a life insurance policy numbered 351901397 with the Respondent. The

DLA died on 15.12.2003 due to Cardio Respiratory Failure. When the complainant

approached the Respondent for death claim, the same was repudiated on the ground of

suppression of material facts regarding health of DLA in the Proposal form of policy in

question. Subsequently, the Complainant had referred the case to Respondent’s claim

review committee for reconsideration, which was also upheld by them. The claimant

preferred a complaint to this Office.

Observations of Ombudsman : I have gone through the materials on records and

submissions made during hearing and my observations are summarized as follows:

The Complainant contended that the agent filled up the proposal form and as such the

DLA might not be aware that he was suffering from any disease and there was no

intention to conceal any information.

The Respondent stated that DLA was already suffering from cancer of esophagus,

Diabetes Mellitus for which he had also undergone chemotherapy on various occasions

prior to taking policy, which was concealed by him in the proposal form of the policy in

question.

It is observed from hospital records dated 10.12.2002 that the DLA was diagnosed for

‘Invasive moderately differentiated aquamous cell Carcinoma of esophagus with

H.pylori gastritis’. The Esogastroduodenoscopy & CT scan report dated 09.12.2002 &

13.12.2002 shows that the DLA was a known case of Carcinoma of esophagus and

diagnosed for Carcinoma esophagus and was advised for follow-up bone scan after 6

months. Chemotherapy flow sheet shows that the DLA had on various occasions

undergone chemotherapy during the period from 26.12.2002 to 19.10.2003 whereas the

proposal form dated 15.06.2003 signed by DLA shows that he was keeping normal

health at the time of taking policy. It is also observed from claim forms B&B1 that the

primary cause of death of DLA was Cardio Respiratory Failure and Secondary cause

was Carcinoma esophagus and that the DLA was suffering from DM with Hypertension

three months back.

Insurance is a contract of Utmost Good Faith where both the parties are required to

disclose all the material facts. In the present case, DLA has given incorrect statement

regarding his health to mislead the Respondent to accept his proposal on his life. Had

the DLA disclosed his past illness, it would have certainly affected the Respondent’s

underwriting decision.

In view of the circumstances stated above, I am of the considered opinion that the

decision of the Respondent to repudiate the claim on this ground is fair and justified. I

found no reason to interfere with the decision taken by the Respondent. Hence the

complaint is dismissed without any relief.

Bhopal Ombudsman Centre

Case No. LI - 633 - 21 / 11 - 06 / BPL

Smt. Lilly Saluja

Life Insurance Corporation of India

Award Dated 30.12.2005

Smt. Lilly Saluja, Complainant is the wife of late Shri Devendra Singh, DLA. DLA had a

life insurance policy numbered 352232339 with the Respondent taken on 15.03.2004.

The DLA died on 24.08.2004 due to Cerebral Hemorrhage. When the complainant

approached the Respondent for death claim, the same was repudiated on the ground of

suppression of material facts regarding health of DLA in the Proposal form of policy in

question. Subsequently, the Complainant had referred the case to Respondent’s claim

review committee for reconsideration, which was also upheld by them. The claimant

preferred a complaint to this Office.

Observations of Ombudsman : I have gone through the materials on records and

submissions made during hearing and my observations are summarized as follows:

The Complainant contended that the DLA was in good health at the time of taking

above policy, which was confirmed by the Medical Examination Report done by

Respondent’s Medical examiner. Further the Complainant added that the DLA was not

suffering from any disease and there was no concealment of any information.

The Respondent stated that the DLA had a history of HTN with Brain Hemorrhage 5

years back at Chandigarh which was not disclosed by him in the proposal form and the

cause of death has also been Cerebral Hemorrhage.

It is observed from hospital records dated 23.08.2004 that the DLA was a known

patient of HTN with Brain Hemorrhage 5 years back whereas the proposal form dated

08.03.2004 signed by DLA shows that he was keeping normal health at the time of

taking policy in question. It is also observed from claim form B&B1 that the primary

cause of death of DLA was Cerebral Hemorrhage and secondary cause was Cardio

Respiratory Failure and that the DLA was a known patient of HTN with Cerebral

Hemorrhage.

Insurance is a contract of Utmost Good Faith where both the parties are required to

disclose all the material facts. In the present case, there are sufficient evidential proofs

to show that DLA was sick at the time of taking policy and that he has given incorrect

statement regarding his health to mislead the Respondent to accept his proposal on his

life. Had the DLA disclosed his past illness, it would have certainly affected the

Respondent’s underwriting decision.