16(1)/17of THE INSURANCE OMBUDSMAN RULES, 2017 ...

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF ODISHA

(UNDER RULE NO: 16(1)/17of THE INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN – Shri Suresh Chandra Panda

CASE OF (Mrs Usha Parida Vs. SBI Life Ins. Co.ltd) COMPLAINT REF: NO: BHU-L-041-2021-0073

AWARD NO: BHU-A/LI/103/ 2020-2021

1. Name & Address of the Complainant

Mrs. Usha Parida, At/Po- Putiapadar, PS- Hinjilicut Dist- Ganjam- 761102

2. Policy No: Type of Policy Duration of policy/Policy period

35786451004, 17369378206 & 35631111702 Life 30.08.2017, 24.08.2018 & 01.02.2019

3. Name of the insured Name of the policyholder

Late Ranjan Parida - do-

4. Name of the insurer SBI Life Insurance co. ltd

5. Date of Repudiation NA

6. Reason for repudiation NA

7. Date of admission of the Complaint

03.07.2020

8. Nature of complaint Repudiation of death claim

9. Amount of Claim Rs.1800000/-

10. Date of Partial Settlement NA

11. Amount of relief sought Rs.1800000/-

12. Complaint registered under Rule no: of Insurance Ombudsman Rules

13(1)(b)

13. Date of hearing/place 09.10.2020/ Bhubaneswar

14. Representation at the hearing

a) For the Complainant Usha Parida

b) For the insurer Pallavi Patnaik (call on GotoMeet)

15 Complaint how disposed Under Insurance Ombudsman Rule 17.

16 Date of Award/Order 09.10.2020

17) Brief Facts of the Case:- Mrs. Usha Parida filed a complaint stating that the death claim

against the policies on the life of her son has been repudiated by the insurer. The complaint

falls within the scope of Insurance Ombudsman Rules, 2017 and so it was registered.

18) Cause of Complaint:

a) Complainant’s argument:- The complainant stated that her son had purchased the above

mentioned three policies from the present insurer. But unfortunately he died on 23.02.2019.

After his death the complainant, being the nominee under the policies, applied for payment

of insurance amount which was repudiated on the ground of mis-representation of material

facts. Hence, being aggrieved she approached this forum for redressal.

b) Insurers’ argument:- The insurer on the other hand argued that the DLA is reported to have

died on 23.02.2019. During the assessment of death claim, it was found that the DLA had not

disclosed his previous life insurance policies, rejection of insurance proposal by other insurers

and mis-stated his income in the proposal form. The DLA had procured the policies by

suppressing material information regarding his previous policies with Bajaj Allianz Life

Insurance, India First Life Insurance and Max Life Insurance. The DLA resorted to insurance

shopping deliberately knowing well that his proposal would be declined if he disclosed his

actual insurance cover which is a material fact. The DLA had done insurance shopping within

a short duration of one and half year by applying for policies with an intent to defraud the

Insurance companies. It is clear that the DLA purchased the insurance policies in a

programmed manner with an intention to defraud the insurance industry and committed

fraud on the company. So, the claim was repudiated by the insurer.

19) Reason for Registration of Complaint: - scope of the Insurance Ombudsman Rules 2017.

This is a complaint against non-settlement of death claim by the Insurer.

20) The following documents were placed for perusal.

a) Photo copies of policy documents.

b) Photo copy of representation to Insurer and its reply.

21) Result of hearing with both parties(Observations & Conclusion):-

After a careful scrutiny of the documents submitted by the insurer it was observed that the

deceased Life Assured had purchased 3 (three) policies without disclosing his previous

policies of other Insurers which was material for underwriting the policies. The policies

purchased was to the tune of Rs.72,87,786 from different Insurers in a span of one and a half

year. According to the Insurer, the insurance policies were obtained in a programmed manner

with an intention to defraud the Insurance industry. Further, in the proposal form the

occupation of DLA was different in all the three policies and the income was not adequate to

pay the premium of all the policies. These are all material facts for the insurer for

consideration of insurance. Had it been disclosed, the insurer’s underwriting decision would

have been different. So, the decision of the insurer in repudiating the claim for suppression of

material fact is justified. However, the intention of fraud by the DLA is ruled out as the DLA

was educated only upto 8th Std and all the proposal forms were filled up by different Agents

and the DLA might not have been aware of all the questions of the proposal forms and its

implications. Hence, this forum is of the opinion that as it is not an act of fraud, the total

premium paid by the DLA in respect of the subject policies is to be returned by the insurer.

AWARD

Taking into account the facts & circumstances of the case and the submissions made by both

the parties during the course of hearing, it is awarded that the total premium paid by the DLA

in respect of the subject policies is to be returned by the insurer as full and final settlement of

the complaint.

Hence, the complaint is treated as allowed accordingly.

22) The attention of the Complainant and the Insurer is hereby invited to the following

provisions of Insurance Ombudsman Rules, 2017:

a. According to Rule 17(6) of the Insurance Ombudsman Rule 2017, the Insurer shall

comply with the Award within 30 days of the receipt of the award and shall

intimate the compliance to the Ombudsman.

b. As per rule 17 (8) of the said rule, the award of the Insurance Ombudsman shall be

binding on the Insurers.

Dated at Bhubaneswar 09th October. 2020.

(SURESH CHANDRA PANDA)

INSURANCE OMBUDSMAN

FOR THE STATE OF ODISHA

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF ODISHA

(UNDER RULE NO: 16(1)/17of THE INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN – Shri Suresh Chandra Panda

CASE OF (Mrs. Pranayini PattnaikVs. LIC of India CuttackO) COMPLAINT REF: NO: BHU-L-029-2020-0097

AWARD NO: BHU-A/LI/104/ 2020-2021


Mrs. Pranayini Pattnaik, Plot no- 785/1311/1465(54) Mahalaxmi Vihar, Bharatpur, BBSR- 751003


599497420 & 596827577 Life 18.12.2013 & 06.05.2015


Mr Prakash Pattanaik - do-

4. Name of the insurer LIC of India, Cuttack DO




23.07.2020

8. Nature of complaint Non- payment of death claim





13(1)(b)



c) For the Complainant Pradosh Patnaik (Complainant’s son over phone)

d) For the insurer P.C.Sahoo (over phone)



17) Brief Facts of the Case:- Mrs Pranayini Pattanaik has filed a complaint against the insurer

for non-payment of death claim against the policies on the life of her son. The complaint falls

within the scope of Insurance Ombudsman Rules, 2017 and so it was registered.


a) Complainant’s argument:- The above said policies were purchased by the son of the

complainant from the present insurer. Both the policies were revived during the month of

May 2017. Unfortunately the LA met with an accident on 02.07.2017. The insurer has also

settled a claim of Rs.24000/- against a health insurance policy on his life. Later he died on

04.03.2018. After his death the complainant being the nominee in respect of the policies

applied for payment of death claim which was denied on the ground of mis statement of

material fact regarding health conditions.

b) Insurers’ argument:- The insurer on the other hand argued that both the policies were

revived on 06.05.2017 & 10.05.2017 and date of death of the policyholder is on 04.03.2018,

i.e within one year from the date of revival of the policies. The certificate of Hospital

treatment and Medical attendant’s certificate executed by the Capital Hospital, Bhubaneswar

shows that the deceased was received dead in the Hospital with cause of death- Acute

Myocardial Infraction. The postmortem report of the deceased shows that the cause of death

is “ all the findings are ante mortem in nature and consistent with Chronic Cardiovascular

disease – A natural disease process. Death of the deceased is due to circulatory failure as a

result of accute myocardial infraction. Further, the deceased was admitted in KAR CLINIC &

Hospital on 08. 07.2017 and operated on 10.07.2017 for fracture potts (right) and was

suffering from Type-2 diabetes mellitus and HTN. The hospital treatment form executed by

Kar Clinic & Hospital disclosed that the deceased had Type-2 DM and HTN as history of past

illness which he had not disclosed at the time of revival. It is therefore evident that he had

made deliberate mis-statements and withheld material information regarding his health at

the time of revival. So the claim was repudiated.


This is a complaint against non-payment of death claim by the Insurer.



b)Photo copy of representation to Insurer and its reply.

21) Result of hearing with both parties(Observations & Conclusion):- After going through the

arguments and submissions of both the parties it was observed that, the claim was

repudiated by the insurer for two policies on the ground of mis-representation of material

fact regarding his health condition at the time of revival whereas claim was settled for three

policies which were revived at the same time. During the course of hearing, insurer presented

the discharge certificate of Kar Clinic & Hospital for operation of fracture potts (right) from

08.07.2017 to 10.07.2017 with mention of Type-2 DM and HTN as history of past illness

which the deceased had not disclosed at the time of revival. But there is no mention in the

Discharge certificate regarding the duration of his past illness. Moreover, health insurance

claim was settled for the aforesaid period of treatment which was not disputed by the

Insurer. The claim forms filled up by the hospital for health insurance revealed that the

history of DM and HTN is of 1 month only which is after the date of revival. There is no

evidence that the DM and HTN were pre-existing at the time of revival. . Medical done by the

insurer at the time of revival did not reveal any adverse health condition and thus revival

was allowed by the Insurer. Hence, repudiation of claim by the insurer is not justified.

Keeping in mind the above facts, this forum is of the opinion that the claim is to be admitted

by the insurer for full Sum Assured under both the policies as per rules.

22) The attention of the Complainant and the Insurer is hereby invited to the following

provisions of Insurance Ombudsman Rules, 2017:

c. According to Rule 17(6) of the Insurance Ombudsman Rule 2017, the Insurer shall

comply with the Award within 30 days of the receipt of the award and shall

intimate the compliance to the Ombudsman.

d. As per rule 17 (8) of the said rule, the award of the Insurance Ombudsman shall be

binding on the Insurers.

Dated at Bhubaneswar 014th October. 2020.

(SURESH CHANDRA PANDA)

INSURANCE OMBUDSMAN


AWARD

Taking into account the facts & circumstances of the case and the submissions made by both the

parties during the course of hearing, it is awarded that the claim is to be admitted by the insurer

and full Sum Assured is to be paid under both policies to the claimant along with bonus if any.

Hence, the complaint is to be treated as allowed accordingly.

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF ODISHA (UNDER RULE NO: 16(1)/17of

THE INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN – Shri Suresh Chandra Panda

CASE OF (Mr Gourishankar Prasad MishraVs. Bajaj Allianz Life Insurance co. ltd) COMPLAINT REF: NO: BHU-L-006-2021-0095

AWARD NO:BHU-A/LI/115/2020-2021


Mr Gourishankar Prasad Mishra,Qrts No. – D/26, Unit- 6(H.C) Bhubaneswar-751001


348311001 Life 28.05.2018


Sushree Harichandan - do-

4. Name of the insurer Bajaj Allianz Life Insurance co. ltd




23.07.2020

8. Nature of complaint Rejection of death claim





13(1)(b)



a) For the Complainant Gourishankar Prasad Mishra

b) For the insurer Saswata Banerjee, Zonal Legal Manager



17) Mr Gourishankar Prasad Mishra (herein after referred to as the complainant) had filed a

complaint against the decision of Bajaj Allianz Life Insurance co. ltd (herein after referred to as

the respondent Insurance company)alleging repudiation of death claim in his wife’s policy no.

348311001

18) Cause of complaint: Complainant’s argument:, )The complainantMr Gourishankar Prasad

Mishra is the nominee in his wife’s policy no .348311001.The LA Mrs Sushree Harichandan

expired on 01.06.2019. The LA had transferred a House Mortgage Loan Account from LIC to

Bajaj Housing Finance Ltd. In May 2018 and the policy no. 348311001 had been issued with

effect from May 2018 connecting the housing loan account. The sum assured was Rs 842380/-

with premium of RS 50000/-.After the death of LA, the complainant, who is the nominee in the

policy approached the insurer for payment of death claim in the policy. The insurer rejected the

claim on the ground of non- disclosure of the fact that the LA was suffering from AIH with Flair

since 2017.The complainant had approached the claims review committee of insurer with all

relevant documents and the claim was also rejected by them.The complainant states that the

rejection is illegal and unsustainable in the eyes of law and hence he approached this forum for

redressal.

Insurer’s argument:

The insurer has filed SCN and stated that on the basis of proposal and other documents

submitted , the policy was issued on 28.05.2018 to the wife of the complainant who died on

01.06.2019 within 2 years from the date of policy. Hence, the case was investigated and it was

found that the deceased life assured was suffering from Auto Immune Hepatitis with Flare and

was a known case of Hypothyroidism since 2017 which was mentioned in the report of KIMS

Hospital. The DLA was treated in Apollo hospital in 2017 for Icterus . The DLA herself being a

doctor was very much aware of her health condition which was fraudulently suppressed in the

proposal form and hence, the claim was repudiated.

Hence, the insurer states that the present complaint is liable to be dismissed.






21)Result of hearing with both parties(Observations & Conclusion):- After going through the

submissions and arguments of both the parties it was observed that the wife of the

complainant had transferred a House Mortgage Loan Account from LIC to Bajaj Housing Finance

Ltd. in May 2018 and a policy had been issued with effect from May 2018 connecting the

housing loan account. At the time of purchase it was the duty of the LA to disclose all her health

details to the insurer. As per the death summary of KIMS Hospital submitted by the insurer, the

deceased Life Assured had been treated for Icterus diagnosed as drug induced hepatitis, AIH

Flare, Abdominal hernia repair in Apollo Hospital in 2017. i.e. prior to the issue of policy which

were found to be material for insurance. Correct health and life style information of the person

seeking for insurance is very important for the underwriter to assess the risk involved in the

issuance of a policy. It is evident that DLA had complete knowledge of her previous medical

history and deliberately suppressed the same from the company, which led to the issuance of

the policy. Thus the DLA had deliberately concealed the material facts with regard to her health

and hence did not allow the Insurer to undertake a fair and correct underwriting of the policy.

Had the pre-existing disease of the DLA been disclosed in the proposal form, the policy would

not have been issued by the Insurer. Taking into consideration all the above fact, this forum

decides that the complaint is not sustainable and is to be treated as dismissed.

Dated at Bhubaneswar on 21st Oct. 2020 (Shri Suresh Chandra Panda )

INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF ODISHA (UNDER RULE NO: 16(1)/17of

THE INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN – Shri Suresh Chandra Panda

CASE OF (Kalyani NahakVs. PNB Metlife India Ins.Co. ltd) COMPLAINT REF: NO: BHU-L-033-2021-0092

AWARD NO: BHU-A/LI/112/2020-2021


Mrs Kalyani Nahak,w/o Ramesh Ch. Nahak,At- Jharedi Radha Govindapur, Po- Palur, Rambha, Ganjam


21084966 21073040 Life 16.05.2013 25.04.2013


Mrs Kanchana Nayak - do-

4. Name of the insurer PNB Metlife India Ins.Co. ltd




29.06.2020


9. Amount of Claim Rs 750000/- Rs214000/-


11. Amount of relief sought


13(1)(d)

AWARD

Taking into account the facts & circumstances of the case and the submissions made by

both the parties during the course of hearing, the complaint is treated as dismissed.



a) For the Complainant Kalyani Nahak

b) For the insurer Arijit Basu



17) Mrs Kalyani Nayak(herein after referred to as the complainant) had filed a complaint

against the decision of PNB Metlife India Ins.Co. ltd(herein after referred to as the

respondent Insurance company)alleging death claim repudiation in policy no. 21073040 and

21084966 of LA Late Kanchana Nayak, grand mother of complainant.

18) Cause of complaint:

Complainant’s argument:, Late Kanchan Nayak, Grandmother of the complainant had

purchased two life insurance polices from the respondent insurance company. The

complainant was the nominee in both these policies. The LA expired on 24.05.2014, hence

the complainant approached the insurer for claim payment. However the insurer repudiated

the claim on both the polices.

Insurer’s argument:

The insurer has filed SCN and stated that on the basis of proposal and other documents

submitted the policy was issued to the grandmother of the complainant. The Insurer alleges

that the policy was taken after the death of the DLA on 14.04.2013 due to old age as she was

75 years of age then. The policies were taken after the death of the DLA. Moreover, the DLA

was also not insurable due to high age and her date of birth as 28.03.1965 was manipulated

for taking the policies. This fact is substantiated by the voter id cards of his 2nd son who was

aged 48 years (Born in 1977) on the date of death of DLA . The death certificate obtained was

also proved to be false. Hence, the claim has been repudiated on grounds of fraudulent

intention behind taking the policies and liable to be dismissed.

19) Reason for Registration of Complaint: - Scope of the Insurance Ombudsman Rules 2017.





21)Result of hearing with both parties(Observations & Conclusion):-

After going through the argument and submissions of both the parties it was observed that

the policies were taken after the death of the life assured. This fact is substantiated by the

age proof of the 2nd son of DLA whose age (48 years) was same as that of DLA at the time of

taking the policy in 2013. The actual age of the DLA was 75 years who died of old age on

14.04.2013 and policies were taken on 25.04.2013 & 16.05.2013 after the death of

policyholder. A death certificate of CHC Khandadeuli was given by the claimant which was

verified and found to be fake as the Registrar of CHC Khandadeuli has denied issuing such

certificate. All the papers were fabricated and fake for issuance of policy to a non-existent

person only to defraud the Insurer. The matter has to be investigated by the Insurer to put a

check on such forgeries. Hence, this Forum feels that papers were forged to avail the death

benefits by the complainant, the insurer has rightly repudiated the claim against the policies

in dispute.

Dated at Bhubaneswar on 21st Oct. 2020 (Shri Suresh Chandra Panda )

INSURANCE OMBUDSMAN


PROCEEDINGS OF THE INSURANCE OMBUDSMAN, DELHI

(Under Rule No. 13 r/w 17 of the Insurance Ombudsman Rules, 2017)

Ombudsman: Shri Sudhir Krishna

Case of Binita Topno versus Max Life Insurance Co. Ltd.

Complaint Ref. No.: DEL-L-032-2021-0220

Case No.: LI/Max/125/20

1. Name & Address of The

Complainant

Smt. Binita Topno,

496-G Block Ayanagar , Phase-6 New Delhi 110047

2. Policy No.

Type of Policy

Policy term/Policy Period

878489624

Max Life Whole Life

15 years

3. Name of the insured

Name of the policy holder

Thomas Topno

Thomas Topno

4. Name of Insurer Max Life Insurance Company Ltd.


6. Reason For Grievance Death claim Dispute

7. Date of receipt of the Complaint 12-8-2020

8. Nature of Complaint Death Claim Dispute

9. Amount of Claim Rs. 5.64 lakh

AWARD

Taking into account the facts & circumstances of the case and the submissions

made by both the parties during the course of hearing, the complaint is treated as

dismissed.


11. Amount of Partial Settlement Rs. 1,68,428

12. Amount of relief sought Rs. 5.64 lakh, less the sum received of Rs. 1,68,428

13. Complaint registered under Rule

no:

Insurance Ombudsman Rules,

2017

Rule 13(1)(b)- any partial or total repudiation of claims by

an insurer

14. Date of hearing 01.10.2020

Place of hearing Delhi, Online via WebEx


a) a) For the Complainant Smt. Binita Topno,the Complainant

b) b) For the Insurer Smt. Anchal Yadav, Sr. Manager (Legal)

16. Date of Award/Order Award under Rule 17/ 01.10.2020

17. Brief Facts of the Case: Smt. Binita Topno (hereinafter referred to as the Complainant) has filed this

complaint against the decision of Max Life Insurance Co. Ltd. (hereinafter referred to as the Insurer

or the Respondent Insurance Company) alleging wrong repudiation of death claim.

18. Cause of Complaint:

a) Complainant’s Argument: The Complainant’s husband, who had purchased a policy bearing

no.878489624 on his life, expired on 17.03.2020. The Complainant submitted all documents to the

Insurer, but her claim was not settled. Now she has approached this form for claim amount.

b) Insurer’s Argument: The Insurer in their Self-contained Note (SCN) have submitted that policy

No.53552779 was issued on 27.12.2012.The Complainant has approached the company with a

death claim request on 13.07.2020. After investigating the matter and verifying the records, the

company found that the claim was paid as per non-forfeiture option chosen, since the policy was

on RPU (Reduced paid up) mode on the date of death of the life assured. It is submitted that the

premium due on 27th Dec.-2019 was not received and thus after expiry of the grace period and as

per terms of policy the policy went into reduced paid up mode (RPU) in December2019. As the

non-forfeiture option chosen at inception was RPU, the Company had repudiated the claim as per

the terms and condition of the policy and existing insurance laws and regulations. In view of the

above facts, the case is devoid of any merit and may be dismissed.

Case of Binita Topno versus Max Life Insurance Co. Ltd.


Case No.: LI/Max/125/20

19. Reason for registration of Complaint: Mis-sale.

20. The following documents were placed for perusal.

a) Copy of policy.

b) Self Contained Note.

c) Copy of GRO Letter.

21. Result of hearing with the parties (Observations and Conclusion):

Case called. Parties are present and recall their arguments as noted in Para 18 above.

The Complainant states that she had visited a Branch office of the Insurer, where she was informed

that she was entitled to receive the sum insured of Rs. 5.64 lakh, whereas the Insurer gave her Rs.

1,68,428 only.

The Insurer statesthat the deceased policyholder had not paid the annual premium due on

27thDecember 2019 and after expiry of the grace period of one month and as per terms of the

policy, the policy went into Reduced Paid up (RPU) mode in December 2019, as per the non-

forfeiture option chosen at proposal stage. Accordingly, as per the policy terms,since the policy was

on RPU mode on the date of death of life assured on 17th March 2019, no death claim was payable

and as per clause 14 of the policy, the RPU sum in the policy amounting to Rs.1,68,428.01 was

released.

Upon examination of the arguments and the evidence submitted by the parties, I conclude that the

Insurer was justified in repudiating the death claim and paying the sum of of Rs. 1,68,428 as per

clause 14 of the policy. Pursuantly, the complaint deserves to be rejected.

Award

The complaint is rejected.

(Sudhir Krishna)

Insurance Ombudsman, Delhi

01 October 2020


(Under Rule No: 13 r/w 17 of the Insurance Ombudsman Rules, 2017)


Case of Swapan Kumar Yadav versus Life Insurance Corporation of India


Case No.: LI/LIC/159/20

1. Name & Address of the

Complainant

Shri Swapan Kumar Yadav

J-1016, Jahangir Puri

Delhi- 110033

2. Policy No.

Type of Policy

Policy Term/Premium Paying Term

117916453

Life- Endowment / Regular

20years/15years

3. Name of the Insured

Name of the Policy Holder

Late Sarita Yadav

Late Sarita Yadav

4. Name of Insurer LIC of India

5. Date of Rejection 12.03.2020

6. Reason for Grievance Repudiation of Death Claim

7. Date of receipt of the Complaint 15.09.2020

8. Nature of Complaint Repudiation of death claim

9. Amount of Claim Rs. 100000/-

10. Date of Partial Settlement ---

11. Amount of Partial Settlement ---

12. Amount of relief sought Rs. 100000/-

13. Complaint registered under Rule

no: Insurance Ombudsman

Rules,2017

13(b) any partial or total repudiation of claims by the

life insurer, General insurer or the health insurer ;

14. Date of hearing 29.10.2020

Place of hearing Online Video Conferencing via Cisco WebEx App


a) For the Complainant Shri Swapan Kumar Yadav, the Complainant

b) For the Insurer Smt. Kala Sivaramakrishnan, Manager (CRM)


17. Brief Facts of the Case:

Mr. Swapan Kr. Yadav (hereinafter referred to as the Complainant) has filed this complaint

against the decision of LIC of India (hereinafter referred to as the Insurer or the Respondent

Insurance Company) alleging wrong repudiation of death claim under policy no. 117916453.


a. Complainant's Argument: The Complainant vide letter dated 17.09.2020 submitted that

his mother purchased policy no. 117916453 on 18.02.2015. She died on 22.08.2018,

until her death, all premium were paid under the policy. Yet, the insurer repudiated

death claim. He has now approached this forum for release of death claim under the

policy no. 117916453.




b. Insurer’s Argument: The Insurance Company vide SCN dated 26.10.2020 submitted that

the policy no. 117916453 on the life of Lt. Sarita Yadav was revived on 07.12.2016 and

death claim arose on 22.08.2018. Since, the policy had not completed 3 years from date

of revival therefore it was treated as an early claim. Hence, the claim was investigated.

During investigation, it was found that at the time of revival of policy, the DLA had not

disclosed her illness in Question No. 2 and 4 of Declaration of Good Health as she was a

known case of T2DM/HTN/CKD and has been undergoing dialysis at Banwari Lal

Charitable Dialysis Center since 29.09.2016. Hence, the death claim under the policy was

repudiated and premia paid was forfeited, as the insured had deliberately concealed

material fact regarding her health in Declaration of Good Health Form.

19. Reason for registration of Complaint: Repudiation of death claim.

20. The following documents were placed for perusal:

a) Copy of policies.

b) Self Contained Note from the Insurer.

c) Revival Form

d) Dialysis details from Banwari Lal Charitable Dialysis Center

21. Result of hearing with the parties (Observations and Conclusion):


The subject policy was taken on 18.02.2015 (DOC) with quarterly premium payment. As the

proposer, who is now the deceased life assured (DLA) did not pay 3 quarterly premiums due

in May, August and Nov 2016, the policy went into lapsed status. The policy was revived in

December 2016. In the proposal form for revival, there were questions asked from the

proposer about her health and she had for Qn 2a & 4, replied that she had given Good

Health declaration for herself. The proposer expired on 22.08.2018 and the Complainant

being the nominee preferred the death claim. While examining the claim, the Insurers

discovered that she was undergoing dialysis 29.9.2015, 03.10.2015, 06.10.2015 and many

other dates. Upon observing this misrepresentation, the Insurer repudiated the claim vide

letter dated 30.10.2019, wherein the Complainant was also advised to make an appeal to

the Zonal Committee of the Insurers. The Complainant’s appeal was rejected by the Zonal

Committee on 12.03.2020, whereafter he approached this forum.

The Complainant states that the subject policy of his mother (DLA) had commenced on

18.02.2015 and her dialysis had commenced after that and therefore, as she expired on

22.08.2018, which was 3 years after the commencement of the policy, the repudiation of the

death claim under section 45 of the Insurance Act would not be applicable. He also states




that the original proposal form as well as the revival proposal form for the subject policy

were filled in by the agents and so her mother should not be faulted for any incorrect

declarations. The Insurers observes that the DLA/Proposer was a graduate and could not

take excuse of signing these forms without understanding the contents.

I have examined the arguments and the evidence submitted by the Complainant and the

Insurers. Section 45 of the Insurance Act was amended in 2015, but the amendment had

come into force from 26th December 2014. As per this provision, the policy becomes immune

to any questions after the expiry of three years from the date of issuance or of revival,

whichever is later. However, within the period of three years, concealment of any material

facts by the proposer would make the policy liable for adverse action. As the subject policy

was revived in December 2016, the immunity against questioning would be available only

after December 2019. As the Insurer discovered the misrepresentation of the material facts

relating to the serious ailments of the DLA within this period and repudiated the claim in

October 2019, the action of the Insurer is not incorrect.

The Complainant’s argument that the fault of mis-representation of material facts in the

revival proposal form would lie on the agent, is also not acceptable, as the proposer while

signing the revival form takes the responsibility for all the averments made by her in the

application forms.

All the facts mentioned above lead to the conclusion that the repudiation of the death claim

by the Insurers was justified. Pursuantly, the complaint would deserve to be rejected.

Award

The complaint is rejected.

(Sudhir Krishna)


October 29, 2020


(Under Rule 13 r/w 17 of the Insurance Ombudsman Rules, 2017)


Case of Ramanjeet Singh Versus Edelweiss Tokio Life Insurance Co. Ltd.


Case No.: LI/Edelweiss/124/20

1. Name & Address of the Shri Ramanjeet Singh (Nominee)

Complainant 11/62, G.F. (West), Punjabi Bagh, New Delhi-110026

2. Policy No. 500501817E

Type of Policy Life- Endowment / Regular

Policy Term/Premium Paying

Term 20 year / 10 year

3. Name of the Insured Kamaljit Singh

Name of the Policy Holder Kamaljit Singh

4. Name of Insurer Edelweiss Tokio Life Insurance Co. Ltd.

5. Date of Rejection 31.03.2020

6. Reason for Grievance Repudiation of Death Claim


8. Nature of Complaint Repudiation of Death Claim

9. Amount of Claim Rs. 19,13,750/-

10. Date of Partial Settlement Rs. 1,91,388.12 (Refund of Premium on 30.03.2020)

11. Amount of Partial Settlement

12. Amount of relief sought Rs. 19,13,750/-

13.

Complaint registered under Rule

of

13(b): any partial or total repudiation of claims by the

life

Insurance Ombudsman Rules,

2017 insurer

14. a) Date of hearing 09.10.2020

b) Place of hearing Online Video Conferencing via Cisco WebEx App


a) For the Complainant 1. Shri Ramanjeet Singh, the Complainant

2. Smt. Amrit Kaur, M/o the Complainant

b) For the Insurer Shri Ayan Chakraborty, Manager Legal


17. Brief Facts of the Case:

Shri Ramanjeet Singh, nominee (hereinafter referred to as the Complainant) has filed

this complaint against the decision of Edelweiss Tokio Life Insurance Co. Ltd.

(hereinafter referred to as the Insurer or the Respondent Insurance Company) alleging

wrong repudiation of death claim on his father under policy number 500501817E.


Complainant's Argument: The Complainant’s father late Shri Kamaljit Singh aged 58 years had

purchased aforesaid policy from Edelweiss Tokio Life Insurance on 26.03.2019. He met with an

accident in October 2019 and underwent treatment at Sir Ganga Ram Hospital for injury and

swelling in leg. During the course of treatment, he was also diagnosed with heart disease. He

(nominee) lodged death claim on his father who died on 11.02.2020. The Company rejected

admission of his claim on 31.03.2020 on the basis of misrepresentation, suppression or non-

disclosure of material facts at the time of taking policy and refunded the deposited premium

amount of Rs. 1,91,388.12 vide UTR No. CITIN20050708875 on 31.03.2020. He approached the

Insurer on 02.04.2020, 07.04.2020, 08.04.2020 and 19.04.2020 with a plea that no facts were

hidden from the Company but the Insurer on 30.04.2020 regretted to accede to his request for

admission of the claim. He represented again on 13.07.2020 and submitted discharge summary




dated 28.10.2019, which has no mention of previous treatment history, raised question

about the medical test done by the Insurer at the time of acceptance of proposal. The

Insurer on 16.07.2020 denied the allegation and rejected his request for admission of

claim on 16.07.2020. Now he approached this forum for relief.

b. Insurer's Argument: The said policy was issued to the Deceased Life Assured (DLA) on

25.03.2019 on the basis of duly filled proposal form. The Complainant (nominee)

submitted the claimant statement on 13.03.2020 informing about the sad demise of

DLA (father) on 11.02.2020 due to heart attack. The said death claim was repudiated on

31.03.2020 on the basis of non-disclosure of pre-existing medical adversities. On

request of the Complainant dated 02.04.2020, the Insurer reconsidered and upheld

their decision to repudiate the claim. Since it was an early death claim, the Insurer,

during investigation procured discharge summary from Sir Ganga Ram Hospital dated

28.10.2018 (submitted as Annexure-C1), which mentions that DLA suffered from

Coronary Artery Disease, Acute coronary Syndrome, Diabetes’s Mellitus, Chronic kidney

Disease and Hypertension. These facts were not disclosed at the time of taking policy in

March 2019 and anytime thereafter. The DLA misled the company by answering point

no. 13 of proposal form in negative. Hence, death claim under policy no. 500501817E

was repudiated.

19. Reason for registration of Complaint: Repudiation of claim.

20. The following documents were placed for perusal:

a) Copy of policy.

b) Correspondence between the Complainant and the Insurance Company.

c) Self Contained Note from the Insurer with annexures. 21. Result of hearing with the parties (Observations and Conclusion):


The Insurer states that in the Policy Proposal Form signed on 25.03.2019, the DLA had,

under Item 12, declared in the negative under all items relating to his past medical history,

including hypertension, heart ailments, diabetes etc. The policy was issued w.e.f.

26.03.2019 with policy term of 20 years and premium payment term of 10 years. The DLA

had expired on 11.02.2020 following a heart attack. The Complainant being the nominee in

the policy, submitted the death claim, which the Insurer repudiated citing non-disclosure of

material facts of certain relevant pre-existing diseases while submitting the policy proposal

form.

The Complainant has argued that the DLA was never a patient of any major ailment and

that the DLA had fractured his leg some years before, and when he had another fall in

October 2019, he was admitted to the Gangaram Hospital on 28.11.2019, where the

treating doctor discovered for the first time his heart ailment. Therefore, as per the

Complainant, there were no relevant pre-existing diseases that the DLA had not disclosed

while submitting the policy proposal form on 25.03.2019.




The Complainant has submitted a copy of the Discharge Summary dated 05.11.2019 from

Gangaram Hospital where the DLA was then admitted from 28.10.2019 with complaint of

swelling of lower left leg. This Discharge Summary also notes that the patient was a known

case of diabetes and hypertension and on medication for past 3-4 years. It also notes his

past history of necrotizing fasciitis of left leg and grafting done in April 2015. The diagnosis

reports a variety of ailments including CAD, DM, HTN etc. After this discharge, he was

admitted in another hospital (ESI, Basi Darapur) on 11.2.2020 complaining of heart attack

and he expired there the same day.

The Complainant has submitted a copy of the Certificate dated 17.07.2020 from Dr. Aman

Makhija of Gangaram Hospital stating that the DLA was first seen by him on 28.10.2019

when he was admitted with cellulitis of left leg and that he had no past history of any

coronary artery disease as per history taken from him and his family.

The Insurer has submitted copies of Discharge Summary dated 28.10.2018 from Gangaram

Hospital where the DLA was then admitted from 24.10.2018 with complaint of retrosternal

chest pain. This Discharge Summary records a series of ailments of the patient, which

include, but not limited to, increased serum creatinine and high hs-Troponin-1 level, and

that the plan of the hospital for his coronary angiography was curtailed due to his derailed

renal functions. The blood tests done by the hospital on 24.10.2018 had shown, inter alia,

high sugar level of 231 against the desirable range of 70-160 and very high hs-Troponin-1

level of 943.6 against the desirable range of 28.9-39.2. The insured (now the DLA) had

claimed for this hospitalization from the United India Insurance Co. / Heritage TPA through

pre-authorisation for cashless treatment for Rs. 65,313.

Upon careful examination of the arguments and the evidence submitted by the parties, I

conclude that the DLA had not disclosed his relevant pre-existing diseases while submitting

the policy proposal form on 25.03.2019. Pursuantly, the Insurer was justified in repudiating

the death claim and the complaint is liable to be rejected.

Award The complaint is rejected.

(Sudhir Krishna)


09th October 2020

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATES OF A.P., TELANGANA & YANAM

(Under Rule 16(1)/17 of The Insurance Ombudsman Rules, 2017)

OMBUDSMAN - Shri I. SURESH BABU

Complaint Ref. No.HYD-L-019-2021-0216

Award No. IO/HYD/A/LI/0109/20-21

1. Name & address of the complainant Ms .K.Venkata Surya Jyothi Door No.1-67-30, Plot -1, Sector-2, MVP Colony, Visakhapatnam, Andhra Pradesh- 530017

2. Policy No./Collection No. Type of Policy Policy term/Premium paying period

19381158 HDFC Life Super Income Plan. 16 Years/8Years.

3. Name of the Policy holder Mr.K.Srinivasa Raju

4. Name of the insurer HDFC Life insurance Co Ltd.

5. Date of repudiation 18/02/2020

6. Reason for Rejection Suppression of material facts

7. Date of receipt of the Complaint 08/07/2020

8. Nature of complaint Repudiation of death claim.

9. Amount of Claim Rs.3,40,032/-

10. Date of Partial Settlement NIL

11. Amount of Relief sought Rs.3,40,032/-

12. Complaint registered under

Rule No 13.1. ( b) of Insurance Ombudsman Rules

13. Date of hearing/place 28/09/2020/Hyderabad


a) For the complainant Self

b) For the insurer Mr.Vinay Prakash, Senior Executive.

15. Complaint how disposed Dismissed.

16. Date of Order/Award 05/10/2020

17) Brief Facts of the Case:

Ms .K.Venkata Surya Jyothi complained that the insurer had wrongly rejected her

request to settle the death claim on the policy of her husband.

The complaint falls within the scope of the Insurance Ombudsman Rules, 2017 and so it

was registered.

18) Cause of Complaint: Repudiation of death claim.

a) Complainants argument:

Mr.K. Srinivasa Raju took an insurance policy on 19/06/2017 from HDFC life insurance

company and he expired on 01/01/2020. His wife Ms .K.Venkata Surya Jyothi who was the

nominee in the policy gave death intimation and requested the insurer to settle the death

claim. The insurer repudiated the claim stating that, the deceased life assured had suppressed

material facts regarding his health history before taking the policy. The complainant requested

the insurer to reconsider the decision and settle the death claim stating that, the life assured

did’nt have any adverse healthy history before taking the policy but the insurer did’nt settle

the death claim.The complainant approached the Insurance Ombudsman for justice.

b) Insurer’s Argument :

Mr.K. Srinivasa Raju was issued an insurance policy on 19/06/2017 after receiving the

duly completed and signed proposal form along with the first premium. A death intimation was

received from his wife Ms .K.Venkata Surya Jyothi stating that, the life assured expired on

01/01/2020. As it was an early claim an investigation was conducted and it was revealed that,

the life assured suffered from Coronary Artery Disease before taking the policy but did’nt

disclose the same in the proposal form. As the life assured had suppressed material facts

regarding his health history while taking the policy, the claim was repudiated.

19) Reason for Registration of Complaint:- Repudiation of death claim


a)Policy schedule

b) Complaint letter

c) Rejection letter by Insurer

d)Self contained note by the Insurer

21)Result of hearing with both parties (Observations & Conclusion):

Pursuant to the notices issued by this office both the parties attended the hearing held

at Hyderabad on 28/09/2020

On close consideration of submissions made and documents produced it was observed

that the policy in question was taken on 19/06/2017 and the life assured expired on

01/01/2020. The insurer repudiated the death claim stating that, the deceased life assured,

suffered from pre existing ailments, but did’nt disclose the same in the proposal form. On the

other hand, the complainant stated in the complaint letter that, prior to taking the policy the

life assured did’nt suffer from any ailments

he insurer stated in the self contained note (Point No.3.) that, during the investigation, it

was revealed that the Life Assured suffered from Coronary Artery Disease ( CAD ) and had

undergone Angioplasty prior to the inception of the policy and but did’nt disclose the same in

the proposal form. The insurer submitted discharge summary of Tirumala Vijaya Hospital,

Visakhapatnam and it was mentioned in the medical report that, the life assured had taken

treatment in the hospital from 20/07/2019 to 22/07/2019 for Acute Gastroenteritis. It was also

stated in the report that the life assured had a known history of FTD ( Fronto Temporal

Dementia ) and MND ( (Motor neuron disease). It was also stated in the report that the life

assured had undergone PTCA ( Percutaneous Transluminal Coronary Angioplasty ) 12 years ago

and had a past history of CAD ( Coronary Artery Disease). It was understood from the medical

report that, though the life assured was admitted in the hospital for treatment of

gastroenteritis, he had a past history of Psychiatric disorder and heart problem. The doctor had

advised the family members to approach a psychiatrist for further evaluation. Though the

complainant did’nt dispute the discharge summary submitted by the insurer, the contention of

the complainant was that, the life assured did’nt have any serious health problem before

taking the policy except a stroke many years back. She submitted a copy of medical record from

Apollo hospital where in it was clearly stated that a stent was inserted in 2006. The contention

of the complainant was that, the claim could’nt be repudiated on the basis of the stroke which

the life assured had in 2006 as it was many years back before taking the policy and cause of

death was nothing related to the stroke but it was only due to respiratory problem. When, the

complainant was asked whether any doctor was consulted when he had respiratory problem,

she stated that he was taken to Dr.Sri Harsha of Tirumala Vijaya Hospital, Visakhapatnam. She

submitted a copy of death summary issued by Tirumala Vijaya Hospital, Visakhapatnam. It was

mentioned in the death summary that, the life assured was admitted in the hospital with SOB

(Shortness of Breath) and immediately CPR ( Cardio Pulmonary Resuscitation ) was done for 5

to 10 minutes. CPR is an emergency life saving procedure done when the patient’s breathing or

heart beat becomes drastically low. It was also stated in the death summary that, ECG was

taken at 11.23 PM and it showed flat lines and he expired at 11.30 PM on 01/01/2020. Though

the cause of death was mentioned in the death summary as respiratory failure with severe

metabolic acidosis, one of the reasons for metabolic acidosis is acid being accumulated in the

body because of lack of oxygen due to heart failure. It may also be noted that, immediately

after the life assured was taken to the hospital, Atropine injection was given, CPR was done and

ECG was taken. Atropine injection is given, CPR is done and ECG is taken by doctors only when

the doctors feel that the patient has a heart problem. The doctors in the hospital knew very

well that the life assured had previously under gone Angioplasty and had Coronary Artery

disease, as he had taken treatment for Gastroenteritis in the same hospital in July 2019 and the

doctors have mentioned in the discharge summary that life assured had undergone

Angioplasty twelve years back.

During the course of hearing the insurer was questioned as to why medical examination

of the life assured was not conducted before issuing the policy. The insurer stated that the

medical examination was not conducted as the sum assured was only Rs.3,40,032/-.

It was observed that, the life assured answered in negative for the question No. 13 of

the proposal from wherein the proposer was asked whether he had ever suffered from

hypertension, heart disease or stroke. As it was evident from the medical records of Apollo

Hospital that the life assured had undergone Angioplasty and stent was inserted in 2006, it was

clear that, the life assured suppressed the treatment details in the proposal from. Had the life

assured revealed his true health history, the insurer would have called for a detail clinical

examination to arrive at the correct prognosis of the case, access the risk accurately and issue

the policy accordingly or decide whether to issue the policy at all or not.

contract of Insurance is governed by the principle of ‘Uberima fides’. In other words, it

is a contract of utmost good faith wherein the life assured was duty bound to disclose all facts

material to the contract while taking the policy. But it was clearly evident from the medical

records that, the life assured had withheld material information pertaining to his health.

In view of the above, Forum feels that, the repudiation action taken by the insurer was

correct.

AWARD

Taking into account the facts & circumstances of the case and submission made by both the

parties during the course of hearing the insurer is directed to settle the death claim.

In result the complaint is Dismissed

Dated at Hyderabad on the 12th day of October 2020

( I SURESH BABU )

INSURANCE OMBUDSMAN FOR THE STATES OF A.P.

TELANGANA AND CITY OF YANAM






1. Name & address of the complainant Ms.Vengapala Sreedevi H.No. C2/88, 8 Incline colony, Godavarikhani Peddapally (Dst) Andhra Pradesh- 505211.

Policy No./Collection No. Type of Policy Policy term/Premium paying period

7220008806. SBI life Sampoorn Suraksha plan. Group Insurance.

3. Name of the Policy holder Sri.Vengapaka Kannappachari.

4. Name of the insurer SBI life insurance Co Ltd.













b) For the insurer Ms.C.Krishnaveni, Associate Vice President.

15. Complaint how disposed Dismissed



Ms.Vengapaka Sreedevi complained that the insurer had wrongly rejected her request

to settle the death claim on the policy of her husband.


was registered.



Mr.Vengapaka Kannappachari took an insurance policy on 27/12/2018 with SBI life

insurance and he expired on 28/06/2019. His wife Ms.V. Sreedevi who was the nominee in the

policy gave death intimation and requested the insurer to settle the death claim. The insurer

repudiated the claim stating that, the life assured had suppressed material facts regarding his

health history before taking the policy. The complainant requested the insurer to reconsider

the decision and settle the death claim but the claim was not settled.


Mr.Vengapaka Kannappachary was covered under a group insurance policy bearing

number 7220000880.The annual premium in the policy was Rs.8,803/- and the sum assured

was Rs.20,00,000/-. A death intimation was received from his wife Ms.Vengapaka Sreedevi

stating that, the life assured expired on 28/06/2019. The death claim was repudiated as it was

revealed that the deceased life assured Mr.Vengapaka Kannappa Chary was a chronic alcoholic

and was suffering from alcoholic tremors and acute pancreatitis before taking the policy but

did’nt disclose the same in the membership form.



a) Complaint letter.

b). Rejection letter by Insurer.

c) P Form by complainant.

d) Self contained note by the Insurer.



at Hyderabad on 08/09/2020, through on line video call.


that Mr.Vengapaka Kannappachary, aged 49 years, was working as a supervisor in Singareni

collieries. He was covered under ‘Sampoorna Suraksha Group Life insurance scheme’ issued by

SBI Life insurance company. The policy was issued to internet banking customers of State bank

of India who used the YONO application. He submitted the membership form and paid the

insurance premium of Rs.8803/- and was enrolled in the scheme on 27/12/2018.

Unfortunately, he expired on 28/06/2019 and his wife Ms. Vengapaka Sreedvi gave death

intimation and requested the insurer to settle the death claim. The insurer repudiated the

death claim stating that, the deceased life assured was a chronic alcoholic and was suffering

from alcoholic tremors, acute pancreatitis, fatty liver and bilateral pleural effusion prior to the

date of commencement of the policy but did’nt disclose the same in the membership form.

The insurer submitted a copy of medical records of the life assured from Nizam hospital,

Hyderabad. It was clearly evident from the medical records that, the life assured was a chronic

alcoholic and was suffering from alcoholic tremors, acute pancreatitis, fatty liver and bilateral

pleural effusion and taken treatment in the hospital from 19/08/2008 to 05/09/2008 which

was before taking the policy. While taking the policy, the life assured did’nt disclose the details

of the treatment taken by him. Had the life assured disclosed the details of the treatment

taken by him, the insurer would not have issued the policy at all or issued the policy with terms

different from those with which the policy was issued.

The complainant did’nt dispute the details in the medical record submitted by the

insurer but her contention was that, the treatment taken was long back and the cause of death

was not related to the treatment taken, but it was sudden. The argument of the complainant

was that, even though the details of the treatment taken by the life assured before taking the

policy were not disclosed in the membership form, it was not correct to repudiate the claim on

that ground as the life assured did’nt die because of the ailment for which he had taken

treatment before taking the policy. To ascertain the exact cause of death, the complainant was

directed to submit medical records of the life assured from the hospital where he was

admitted before his death. In spite of giving sufficient time, the complainant did’nt submit any

medical records of the life assured. Meanwhile, the insurer submitted Medical Attendant’s

Certificate and Certificate of Hospital Treatment of the deceased life assured. The Certificate

was issued by Dr.R.Sushma, Medical Officer of Aware Gleneagles Global Hospital, L.B.Nagar,

Hyderabad. In the Medical Certificate it was clearly stated that the life assured was admitted in

the hospital on 11/06/2019 and he died in the hospital on 28/06/2019 while taking treatment.

The medical records submitted by the insurer were sent to the complainant and she was

directed to confirm the authenticity of the medical record and she confirmed the same. It was

clearly mentioned in the medical records that he was admitted in the hospital with complaints

of decompensated Chronic liver disease and Jaundice. In the Medical Certificate, it was also

stated that, the life assured was admitted in the hospital on 11/06/2019 and he died in the

hospital on 28/06/2019 while taking treatment. Though the primary cause of death was

mentioned as Cardio Pulmonary arrest, the secondary cause of death was mentioned as

Chronic liver disease, Pancreatitis and hepatic encephalitis. Hence it was very clear that, the

cause of death was closely related to the treatment taken by the deceased life assured in Nizam

Institute of Medical Sciences before taking the policy.

During the course of hearing the insurer was questioned as to why proper medical

examination of the life assured were not conducted before issuing the policy. The insurer stated

that, as it was a group insurance policy, medical examination was not conducted but the policy

would be issued on the basis of the membership form submitted by the member, wherein in

questions relating to the medical history of the member were to be answered. Only if the

member revealed about his ailment he was suffering from the company would come to know

of it and order further tests for evaluation and risk assessment. It was observed that, the life

assured answered in negative for the question No. 1(e) of the membership from wherein the

life assured was asked whether he had suffered from or have been diagnosed with or

treated/hospitalized anytime in the past for lung, Kidney or liver disease. It was evident from

the medical record submitted by the insurer that, the deceased life assured was suffering from

alcoholic tremors, acute pancreatitis, fatty liver and bilateral pleural effusion prior to the date

of commencement of the policy but did’nt disclose the same in the membership form and the

cause of death was also closely related to those ailments.

A contract of Insurance is governed by the principle of ‘Uberima fides’. In other words,

it is a contract of utmost good faith wherein the life assured was duty bound to disclose all

facts material to the contract while taking the policy. But it was clearly evident from the

medical record submitted by the insurer that the life assured had withheld material information

pertaining to his health.

In view of the above, Forum feels that the repudiation action taken by the insurer was correct.

AWARD


parties during the course of hearing the insurer is justified in repudiating the death claim.

In result the complaint is Dismissed


( I SURESH BABU ) INSURANCE OMBUDSMAN FOR THE STATES OF A.P. TELANGANA AND CITY OF YANAM






1. Name & address of the complainant Ms.P.Padma D.No-1-54, Near Ramalayam, Cheepurugudem, Nallajerla ( Mdl ) West Godavari (Dst) - 534176.

Policy No./Collection No. Type of Policy Policy term/Premium paying period

56060540605 SBI life Flexi Smart plan. 10 Years/10Years

3. Name of the Policy holder Sri.P.Srinivasi.

4. Name of the insurer SBI life insurance Co Ltd.


6. Reason for Rejection Policy lapsed.











b) For the insurer Ms.C.Krishnaveni, Associate Vice President.

15. Complaint how disposed Allowed



Ms.P.Padma complained that the insurer had wrongly rejected her request to settle the

death claim on the policy of her husband.


was registered.



Mr P.Srinivas took an insurance policy on 25/10/2013 from SBI life insurance company

limited. His wife Ms.P.Padma who was the nominee in the policy gave death intimation, stating

that, the life assured expired on 06/01/2020 and requested the insurer to settle the death

claim. The insurer repudiated the claim stating that, the policy was in lapsed condition as on

date of death of the life assured. The complainant requested the insurer to reconsider the

decision and settle the death claim, stating that the policy should’nt be treated as lapsed as

there was a premium holiday in the policy, but the claim was not settled.


An insurance policy bearing number 56060540605 was issued to Mr.P.Sreenivas after

receiving the duly signed and completed proposal form.The annual premium in the policy was

Rs.15,000/- and the sum assured was Rs.2,25,000/-. A death intimation was received from his

wife Ms.P.Padma stating that, the life assured expired on 06/01/2020. The death claim was

repudiated as the policy was in lapsed condition as on date of death of the life assured.



a) Complaint letter.

b). Rejection letter by Insurer.

c) P Form by complainant.

d) Self contained note by the Insurer.



at Hyderabad on 28/09/2020, through on line video call.


that Mr. P.Sreenivas aged 42 years, took an ‘SBI Life Flexi Smart’ plan issued by SBI Life

insurance company on 25/10/2013. The policy term was 10 years and the annual premium was

Rs.15,000/-. He paid the premiums regularly, but the renewal premium due on 25/10/2019 was

not paid by him. Unfortunately, he expired on 06/01/2020 and his wife Mr.P.Padma gave death

intimation and requested the insurer to settle the death claim. The insurer repudiated the

death claim stating that, the policy was in lapsed condition as on date of death of the life

assured.

It was observed that, as per condition 7.1 of the policy document, if five years premiums

are paid, the life assured can avail a premium holiday. In other words, if five annual premiums

are paid, the policy would be treated to be in force even if the sixth annual premium was not

paid. As the life assured has paid six annual premiums, he had the option to avail premium

holiday. Anyhow, it was also mentioned in condition 7.2 of the policy document that, the life

assured has to inform in writing before the end of the grace period, his intention to avail

premium holiday. Though the life assured was eligible for premium holiday, the insurer treated

the policy as lapsed as the life assured did’nt inform the company, his intention to avail

premium holiday.

During the course of hearing, the insurer was questioned as to whether there was any

other condition to keep the policy in force, apart from giving intimation in writing, his intention

to avail premium holiday. The representative of the insurer stated that, other than the

condition that, five annual premiums were to be paid, there was no other condition. As, the

prior intimation was only for accounting and valuation purpose the insurer had no right to deny

the premium holiday and the prior intimation becomes a mere formality. Non compliance of a

formality could’nt be treated as a breach of policy condition. In such case, the non payment of

renewal premium itself should have been taken as the option of the life assured to avail

premium holiday. Treating the policy as lapsed was not correct as the policy was not actually

lapsed but only ‘Technically lapsed’. As the intimation by the life assured to avail the premium

holiday, was only a formality, the insurer should’nt have repudiated the claim.

The insurer should have been a little considerate and settled the claim without troubling

the poor widow just because intimation to avail premium holiday was not received from the

life assured but the life assured was otherwise eligible for availing premium holiday. The kind

gesture would have gone a long way in enhancing the brand image of the insurance company,

as the sum assured was also only Rs 2,25,000/-. and not giving an intimation of his intention to

avail premium holiday by the life assured was not a strong reason to repudiate the claim as the

deceased life assured was a loyal customer of the company for six years.

In view of the above, Forum feels that the insurer should settle the death claim.

AWARD


parties during the course of hearing the insurer is justified in repudiating the death claim.

In result the complaint is Allowed


( I SURESH BABU ) INSURANCE OMBUDSMAN FOR THE STATES OF A.P. TELANGANA AND CITY OF YANAM




Complaint Ref. No. HYD-L-008-1920-0937


1. Name & address of the complainant Ms.Saladi Samadanamma H.No.2-35, Illurukothapalle Banaganapalle (Mdl) Kurnool (DST)-518186


501-8377035 Bharti Axa Elite Advantage plan 12 Years/12Years

3. Name of the Policy holder Mr.S.Obulesu

4. Name of the insurer Bharti Axa Life Insurance Company Ltd

5. Date ofRejection by Insurer 31/12/2019

6. Reason for Rejection As per conditions of policy.











b) For the insurer Mr.Snehal Sawant Senior Executive.




Ms.S.Samadanamma complained that the insurer has wrongly rejected her request to

settle the death claim on the policy of her husband.


was registered.

18) Cause of Complaint: Repudiation of death claim

(a)Complainants argument:

S.Obulesu took an insurance policy from Bharti Axa life Insurance Company limited on

28/12/2018. He expired on 25/05/2019 and his wife, Ms. Samadanamma who was the nominee

in the policy gave death intimation and requested the insurer to settle the death claim. The

insurer repudiated the claim stating that, the life assured had suppressed material facts

regarding his health history and income while taking the policy. Ms.S.Samadanamma

approached the Ombudsman for justice stating that her husband had not suppressed any

material facts while taking the policy.

b) Insurer’s argument:

An Insurance policy was issued on 28/12/2018, to Mr.S.Obulesu after receiving the first

annual premium along with the duly signed and completed proposal form. A death intimation

was received from his wife stating that, her husband expired on 25/05/2019 due to sun stroke.

As it was an early claim an investigation was conducted and it was found that the deceased life

assured was suffering with mouth cancer since three years but did’nt disclose the same in the

proposal form. On further investigation it was found that, the life assured had submitted a

proposal for life insurance in Max Life insurance company and the same was rejected by the

insurer but he did’nt disclose the same while taking the present policy. Hence the death claim

was repudiated.

19) Reason for Registration of Complaint:-Repudiation of death claim.


a)Request letter by complainant to Insurance company.

b) Policy schedule.

c) Complaint letter by the complainant to Ombudsman



at Hyderabad on 17/09/2020 through on line video call.

On close consideration of submissions made and documents produced it was

observed that Mr.S. Obulesu who was aged 48 years and doing cloth business took an insurance

policy from Bharti Axa life Insurance Company limited on 28/12/2018. He expired on

25/05/2019 and the complainant Ms. Samadanamma who was the nominee in the policy gave

death intimation and requested the insurer to settle the death claim. The insurer repudiated

the claim and it was observed that the insurer had stated three reasons for repudiating the

claim.

The Insurer stated in the self contained note ( Point No.9) that, the life assured had

given false occupation and income details in the proposal form. The insurer submitted a copy of

ration card in which the annual income of the life assured was mentioned as Rs10,000/- but his

annual income was mentioned as Rs.3,00,000/- in the proposal form. It may be noted that, it is

a common phenomenon in villages to disclose less income in the ration cards as they get

benefits in social security schemes on the basis of the income declared in the ration card.

Regarding occupation of the life assured, it was informed by the complainant that, though he

was doing cloth business he did’nt have any shop but went door to door in the village and the

neighbouring villages and sold cloths. Hence his business would not be registered anywhere

and there would be no documentary evidence like bills or receipts to establish that he was

doing cloth business.

The second reason which the insurer stated for repudiating the claim was that the

diseased life assured had submitted a proposal for insurance in Max life insurance company

which was rejected by the company but he did’nt disclose the same in the proposal form. It was

observed that Max life insurance company had rejected his proposal for insurance stating that

the life assured had an income of only Rs15,000/- per month and hence his standard of living

was poor. The reasons shown by the company were very vague. As the life assured was doing

cloth business, stating that he earned only Rs15,000/- per month was not correct as his income

may vary from month to month. The insurer can’t reject his proposal stating that his standard

of living was poor as there was no criteria on the basis of which the standard of living was

considered as poor. Further the claim of Bharti Axa Life Insurance that, the insured had only

Rs.10,000/- income per year was also proved false as the other insurer i:e Max Life Insurance

company had categorically stated after due enquiry that, the income of the insured was around

Rs1,80,000/- per annum. Reliance on the ration card by the insurer as an evidence to determine

the income of the insured, is found to be truly untenable and in fact this fortifies the Forum’s

view that, all persons understate their income in villages to avail various social security benefits

granted to ration card holders by the state government. In fact, while calculating the income,

the earnings of all the family members should be taken into consideration as it is common in

villages for all family members including women folk to do some work or the other and earn. If

the income of all the family members was taken into consideration, the incomes are sufficient

to pay the premiums. So, the argument of the insurer that the insured had meager income

source does’nt hold ground.

The third reason which the insurer stated for repudiating the claim was that, the life

assured suffered with cancer before taking the policy but did’nt disclose the same in the

proposal form. When the insurer was directed to show any medical record to establish that the

deceased life assured suffered from cancer before taking the policy, the representative of the

insurer requested for a few days time to submit the same. A rehearing of the case was

conducted on 19/10/2020 but the representative of the insurer was not able to submit any

documentary evidence to establish that, the deceased life assured suffered from cancer before

taking the policy. The insurer stated that, an investigator was appointed by them to look into

the case and obtain any evidence regarding the health condition of the life assured before

taking the policy. A video recording of the conversation between the investigator and an

Anganwadi worker was submitted to the Forum. The Anganwadi worker stated in the video

recording that the life assured was suffering with cancer since three years. Anyhow, the

statement given by an Anganwadi worker without any supporting medical records could’nt be

accepted as an evidence to conclude that, the life assured was suffering from cancer before

taking the policy. The insurer had also submitted an unsigned and unattested record from

Anganwadi register in which the date of death of the life assured was entered and the cause of

death was mentioned as ‘cancer’. Anyhow, the extract from the Anganwadi register could’nt be

accepted as it was not attested or signed by an authorized person. Hence, the so called

evidences are inconclusive.

As alleged by the insurer if the life assured had really suffered from cancer before taking

the policy, it would be very unlikely that he would have survived for three years without being

hospitalized or without any medication or procedures like chemotherapy. Hence, the

contention of the insurer that the life assured was suffering from cancer before taking the

policy can’t be accepted.

The insurer invoked provisions of Section 45 of Insurance Act,1938 and rejected the

claim. Rejection of claims as per provisions of Section 45 of the Insurance Act,1938 warrant

production of substantial evidence by the insurer for taking such a decision,but the insurer has

failed to provide any convincing evidence to substantiate the suppression of material fact

regarding health history of the life assured. As the insurer was not able to submit any

documentary evidence by way of any medical records to establish that the life assured suffered

from cancer before taking the policy, the repudiation of the death claim by the insurer was not

corret.

In view of the above the insurer is directed to settle the death claim as the repudiation

of the claim was not supported by any evidence by way of medical reports to establish that

there was suppression of any material facts regarding health and treatment history of the life

assured before taking the policy.

AWARD

Taking into account the facts and circumstances of the case and submissions made by both the

parties, the insurer is directed to settle the death claim.

In result the complaint is Allowed..


( I SURESH BABU )






Complaint Ref. No. HYD-L-019-2021-0144


1. Name & address of the complainant Mr.Sairam Haridasu H.No.13-111/A/1, 1st Floor, Raghavendra Nagar Colony Hyderabad Telangana-501401


18790245 HDFC Life Click 2 Protect Plus plan 39 Years/39Years

3. Name of the Policy holder Mr.C.Prabhajan Kumar

4. Name of the insurer HDFC Life Insurance Company Ltd

5. Date ofRejection by Insurer 06/11/2019












b) For the insurer Mr.Vinay Prakash, Senior Executive.

15. Complaint how disposed Dismissed.



Mr.Sairam Haridasu complained that the insurer has wrongly rejected his request to

settle the death claim on the policy of his brother in law. .


was registered.

18) Cause of Complaint: Repudiation of death claim

(a)Complainants argument:

Mr. C.Prabhanjan Kumar submitted a proposal for an insurance policy to HDFC life

Insurance Company limited on 07/11/2016. He expired on 01/10/2018 and a death intimation

was given by the nominee of the policy and requested the insurer to settle the death claim. The

insurer repudiated the claim stating that, the life assured suffered from Mixed Germ Cell

Tumour before taking the policy but did’nt disclose the same to the insurance company. She

decided to approach the Ombudsman for justice stating that the life assured had not

suppressed any material facts while taking the policy.

b) Insurer’s argument:

An Insurance policy bearing number18790245 was issued on 16/01/2017, to

Mr.C.Prabhanjan Kumar after receiving the first annual premium the duly completed proposal

form. A death intimation was received from the nominee of the policy stating that, the life

assured expired on 01/10/2018 and she requested for payment of death claim. As it was an

early claim an investigation was conducted and it was found that the deceased life assured was

suffering from Mixed Germ Cell Tumour but did’nt disclose the same to the company. Hence,

the death claim was repudiated and the same was informed to the nominee.

19) Reason for Registration of Complaint:-Repudiation of death claim.


a)Request letter by complainant to Insurance company.

b) Policy schedule.

c)Complaint letter by the complainant to Ombudsman

d) Self contained note by Insurance company.


Pursuant to the notices issued by this office, both the parties attended the hearing held

at Hyderabad on 21/09/2020 through on line video call. The complainant Mr. Sairam Haridasu

attended the on line hearing as he had given the complaint on behalf of his sister Ms. Manasa

who was the nominee in the policy.

On close consideration of submissions made and documents produced it was

observed that Mr.C.Prabhanjan Kumar who was aged 31 years and working as a supervisor in

HDFC Securities had submitted a proposal form for an insurance policy from HDFC life

Insurance Company limited on 07/11/2016. He expired on 01/10/2018 and the nominee in the

policy gave death intimation and requested the insurer to settle the death claim. The insurer

repudiated the claim stating that, the deceased life assured suffered from Mixed Germ Cell

Tumor before taking the policy but did’nt disclose the same in the proposal form.

The Insurer submitted a copy of discharge summary from KIMS Hospital, Secunderabad

wherein it was stated that, the life assured was admitted in the hospital on 16/11/2016 and

discharged on 20/11/2016. As per the discharge summary, the life assured was diagonised with

Mixed Germ Cell Tumor. It was also mentioned in the report that he was admitted with

complaint of low back ache since one month, loss of weight of about 9 Kgs, loss of appetite

since 10 days and swelling and hardening of right testis. It was also mentioned in the medical

report that, he was referred to KIMS for further evaluation and management. The contention of

the insurer was that, as it was clearly mentioned in the medical report of KIMS that, there was a

huge lump extending throughout the abdomen, the life assured would have taken treatment

earlier as the huge lump would’nt develop in a short period. When the insurer was directed to

show any medical record to establish that the deceased life assured had taken treatment

before taking the policy, the representative of the insurer requested for a few days time to

submit the same.

A rehearing of the case was conducted on 15/10/2020 but the representative of the

insurer was not able to submit any documentary evidence to establish that, the deceased life

assured had taken any treatment before taking the policy.The complainant was questioned as

to, from which hospital, the life assured was referred to KIMS hospital to find out whether the

Tumor was detected prior to the inception of the policy. The complainant stated that, the life

assured went to KIMS hospital, Secunderabad as an out patient as he had gastric pain and

Dr.Gopichand, urologist of the hospital referred him to Oncologist of the same hospital Dr.

T.Narendra Kumar. The life assured consulted Dr.Narendra Kumar and after testing him,

Dr.Narendra Kumar advised him to get admitted in the hospital. Hence, it was clear that the life

assured was referred to Dr.Nagendra Kumar of KIMS hospital by Dr.Gopichand of the same

hospital on the same day and he did’nt undergo treatment or tests in any other hospital before

consulting KIMS hospital. Hence the contention of the insurer that the life assured had

consulted any other doctor before consulting KIMS hospital does’nt hold any ground. As it was

very clear that the life assured was not aware his health ailment before submitting the

proposal, suppression of any material fact regarding his health and medical history by the life

assured could’nt be established. Anyhow, while submitting the proposal form a declaration was

taken from the life to be assured ( Page No.3 of proposal form ) stating that, the life assured

shall notify the company about any change in the health, occupation or income between the

date of the proposal and the date of acceptance of the proposal for insurance as communicated

in writing by the company. This condition is imposed to enable the insurer to reevaluate the risk

assessment of the life to be assured and take a decision accordingly. This opportunity was not

given to the insurer as the life to be assured did’nt disclose the details of the treatment which

he had taken from KIMS hospital on 15/11/2016. In the proposal form an acceptance is also

taken from the life to be assured to the fact that, the company will be on risk in pursuance for

insurance only after the risk under the proposal form is accepted by the company and the

acceptance is communicated to the life to be assured in writing by the company. This condition

is mentioned in the proposal from to make it clear to the life to be assured, that risk does’nt

start just by submitting the proposal and payment of premium.

As the proposal was submitted by the life to be assured on 07/11/2016 and the policy

was issued on 16/01/2017, he was contractually obliged to inform the details of the treatment

taken by him on 15/11/2016 but he did’nt inform the same to the insurer. As he did’nt inform

the change in his health condition after submission of the proposal form and before issuance of

the policy, the life to be assured had breached the principle of good faith. Had the life assured

informed to the insurer the change in his health condition, the insurer would have reevaluated

the risk assessment and would have taken the decision accordingly whether to issue the policy

or not.

As the life assured did’nt inform the change in his health condition after submission of

the proposal form and before issuance of the policy, the insurer can’t be directed to settle the

death claim.

AWARD

Taking into account the facts and circumstances of the case and submissions made by both the

parties, the insurer is justified in repudiating the death claim.

In result the complaint is Dismissed.


( I SURESH BABU )



17) Brief Facts of the Case: Mr. Muneera Pasha filed a complaint stating that the insurer M/s LIC of India had repudiated death claim preferred by him under the policy of his father on his sudden death due to Heart attack. While the insurer contends that the claim had been rightly repudiated by them on the basis of evidence gathered in respect of treatment under taken by the insured prior to commencement of policy. As his appeal for a review of the repudiation decision to the Zonal Office Claims Dispute Redressal Committee of the insurer has been


(Under Rule 16(1)/17 of Insurance Ombudsman Rules, 2017)

Ombudsman - Shri. I.Suresh Babu, I.R.S

Case between: Mr. Muneera Pasha ………..The Complainant Vs

M/s LIC of India, Hyderabad Division …………The Respondent Complaint Ref. No. HYD-L-029-2021-0429 Award No. : I.O./HYD/A/LI/0117 /2020-21

1. Name & address of the complainant Mr. Muneera Pasha S/o Late Sri Saleem HNo. :1-54,2 nd Ward PO&VL :Mancherla, ML :Gattu Jogulamba ,Gadwal-509129

2. Policy No./Collection No. Type of Policy Duration of Policy/Policy period

649160891 814-16 SA: Rs.2 Lakhs

3. Name of the insured & Policy Holder Late Mr. Saleem

4. Name of the insurer M/s LIC of India Hyderabad

5. Date of Repudiation 20.7.2019

6. Reason for repudiation Suppression of previous ill health at proposal stage




10. Date of Partial Settlement

11. Amount of Relief sought Rs.200000/-

12. Complaint registered under Rule No.13 (b) of

Insurance Ombudsman Rules, 2017

Any partial or total repudiation of claims by the life insurer, general insurer or the health insurer.

13. Date of hearing/place 9.10.2020 /Hyderabad


a) For the complainant Mr. Muneera Pasha

b) For the insurer Mr. Ch V Raghava Rao Manager


16. Date of Order/Award 12.10.2020

rejected, the complainant approached this forum for settlement of the claim by the insurer. Hence the complaint. 18) Cause of Complaint: a) Complainant’s argument: The complainant submitted that his father took insurance policy 649160891 from LIC. He expired on 17.3.2019 due to heart attack. When he preferred death claim under the policy being the nominee, it was repudiated on ground of suppression of previous health history at the time of proposal. The complainant submitted that his family was very poor and his father worked as part time sweeper in a school. He was working as private driver and got a large family to take care. As his father did not know about the terms and conditions, past illness was not mentioned. It was not done intentionally. He has requested that he may be excused for not informing about the treatment and pleaded for settlement of claim. In case it is not possible to settle the claim, he had requested for return of premium which his father paid. The complainant submitted that he has approached Zonal authorities where the decision taken by the Divisional Office has been upheld therefore, the complainant pleaded for intervention of this forum for settlement of the claim. b) Insurer’s argument: In its self contained note dated 22.9.2020, the insurer LIC of India submitted that death claim intimation was received under the policy 649160891 and on enquiry it was found that deceased life assured took treatment for Acute Respiratory failure at Govt. general and chest Hospital at Hyderabad as in patient with IP no. 2325 from 28.4.2015 to 6.5.2015 and had not disclosed the same in proposal dated 29.11.2016. Competent authority repudiated the claim on 20.7.2019. Zonal authorities had upheld the decision taken by the Divisional Office. Life Insurance contract is based on “Utmost Good Faith” on both parties. Suppression of material facts will lead to breach of trust .Therefore the insurer pleaded for dismissal of the complaint by this forum. 19) Reason for Registration of Complaint: - Scope of the Insurance Ombudsman Rules-2017: Any partial or total repudiation of claims by the life insurer, general insurer or the health insurer. 20) The following documents were placed for perusal. a) SCN dt.22.9.2020 b) Complaint letter dated 12.8.2020 c) Repudiation letters dt. 20.7.2019 d) Copies of Policy Schedule & Proposal. 21) Result of hearing with both parties (Observations & Conclusion):

Pursuant to the notices issued by this office, both the parties attended the online

hearing held at Hyderabad on 9.10.2020.

During the hearing, the complainant repeated the contention of his complaint. On the other hand, the representative of the insurer who attended the hearing argued that the deceased life assured had suppressed material information about his health condition at the time of proposal.

On careful consideration of the written and oral submissions of both the parties and the documentary evidence adduced it is noted by the forum that Policy was taken on DOC 28.7.2016/ commencement of risk from 29.11.2016. Duration of the policy was 2 years 3 months. Premiums were paid for 3 years. The proposal form was in English and filled by agent in English. it is noted that the deceased life assured had undergone treatment prior to the date

of proposal for Acute Respiratory failure. He was treated in hospital from 28.4.2015 to 6.5.2015 for Shortness of breath .Cause of death was Heart attack on 17.3.2019, affidavit was submitted in lieu of hospital treatment. The proposal form was signed in telugu by the DLA. Life assured worked as part time sweeper in a school. In the proposal form in Declaration of Health, answers for questions like, during the last five years did you consult medical practitioner for any aliment requiring treatment for more than a week?

Have you been admitted to any hospital nursing home for general check up, observation

treatment or operation? Have you ever been diagnosed with, treated, or advised treatment for liver, stomach ,heart ,lungs, kidney and brain disease the agent has filled “NO” in the proposal dated 29.11.2016. The complainant submitted that his father was unaware of the contents of the proposal form as he was not educated and proposal form was in English.

Insurer had produced the discharge summary from hospital as proof to prove suppression of material information in respect of previous ill health of deceased life assured. As per it, past history of Pulmonary tuberculosis (PTB) and Chronic obstructive pulmonary disease (COPD) five years back and had taken anti-tubercular treatment (ATT) treatment .He was treated for nine days from 28.4.2015 to 6.5.2015 for SOB (shortness of breath) and cough under Rajiv Aarogy Sri scheme at Government general and chest hospital .Life Assureds vital were stable at the time of discharge. ALL TEST REPORTS LIKE SPUTUM AFB ,HIV TEST,S.V.B REACTION WERE NEGATIVE, expect his WBC (white blood cell count) which was more than the normal range and hemoglobin which was below normal range, was 9.2gm .He was treated with Metrogyl antibiotic to treat infections and O2 inhale. HIS AFB (ACID FAST BACILLUS) TUBERCULOSIS DIAGNOSED TEST WAS ALSO NEGATIVE. Insurer submitted that, DMR opinioned that, had life assured disclosed about the disease/treatment in proposal, special reports would have been called and proposal would have been postponed depending on the results of report. The forum noted that the chance of issuing the policy was there, as the results of the test done were negative.

The forum is of the opinion that suppression of information regarding any pre existing disease, if it has not resulted in death nor has no connection to cause of death would not disentitle the claimant for the claim. The cause of death is different from pre existing disease. He died due to heart attack. The alleged concealment was not of such nature as would disentitle the deceased from getting the Insurance. A disease is a long standing ailment, which may have a bearing on the health of the person and may cause the death if the disease is neglected. The forum is of the opinion that certain diseases such as kidney, heart and brain are connected with the life span of a person

and if any misstatement is made in respect of such type of diseases by the person seeking insurance, in such case, it can be believed that knowingly the person, taking the insurance has made misstatement. But if any one suffers from temporary illness and the same was not mentioned at the time of taking insurance, it cannot be stated in true sense that a misstatement in respect of the state of health has been made by the person seeking insurance.

Secondly the forum does not rule out the possibility that the agent, took advantage of the ignorance of the of the life assured, who worked as part time sweeper, who could not understand the questions that were in English and the question which remained unanswered is as to whether he was explained at least the Pre Existing Disease, treatment and hospitalization etc and understood the policy terms and conditions.

The forum doesn’t see any fraudulent intention by the DLA to deceive the insurer. Cause

of death was Heart attack which is not related to treatment under went by DLA prior to proposal. The forum feels that though suppression of information is observed, it could be due to ignorance but not with an intention of fraud. Suppression of PED didn’t have any bearing on

the eventual death of the LA. The forum holds that the action of the insurer in repudiating the death claim is not justified the insurer has no option but to honor the death claim under the policy as per policy terms. Hence the complaint is allowed.

AWARD Taking into account the facts & circumstances of the case and the submissions made by the

both the parties, the insurer is directed to settle the death claim with interest as per Rule

17(7).

In result, the complaint is allowed.

22) The attention of the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules, 2017: a) According to Rule 17(6) the insurer shall comply with the award within 30 days of the receipt

of the award and intimate compliance to the same to the Ombudsman. b) According to Rule 17(7) the complainant shall be entitled to such interest at a rate per annum

as specified in the regulations, framed under the Insurance Regulatory & Development Authority of India Act from the date the claim ought to have been settled under the Regulations till the date of payment of the amount awarded by the Ombudsman.

c) According to Rule 17 (8) the award of Insurance Ombudsman shall be binding on the Insurers. Dated at Hyderabad on the 12th day of October 2020.

(I.SURESH BABU) INSURANCE OMBUDSMAN

FOR THE STATES OF A.P. TELANGANA AND CITY OF YANAM


(Under Rule 16(1)/17 of Insurance Ombudsman Rules, 2017)

Ombudsman - Shri. I.Suresh Babu, I.R.S

Case between: Mrs. K Saritha ………..The Complainant Vs

M/s LIC of India (Karimnagar ) …………The Respondent Complaint Ref. No. HYD-L-029-2021-436

Award No. : I.O./HYD/A/LI/0116/2020-21

1. Name & address of the complainant Mrs. K Saritha W/o Late Ramesh H.No:3-53/2,Vill: Ippal Narsingapur Mdl Hururabad ,Karimnagar, Telangana ,-PIN-505498

2. Policy No./Collection No. Type of Policy Duration of Policy/Policy period

607130562 New Endowment plan 814-16, SA: 5 LAKHS,Hly Rs.16206/-

3. Name of the insured & Policyholder Late Mr K Ramesh (D.O.D-7.9.2018)

4. Name of the insurer M/s LIC of India, Karimnagar Division


6. Reason for repudiation Suppression of ill health at proposal stage.



9. Amount of Claim Rs.500000

10. Date of Partial Settlement Nil

11. Amount of Relief sought Rs.500000

12. Complaint registered under Rule No.13 (b)

of Insurance Ombudsman Rules, 2017

Any partial or total repudiation of claims by the Life insurer, general insurer or the health insurer.

13. Date of hearing/place 9.10.2020 ,Hyderabad


a) For the complainant Mrs. K Saritha

b) For the insurer Mr. N Dasaradhi M(Claims)


16. Date of Order/Award 12.10.2020

17) Brief Facts of the Case: Smt. K Saritha filed a complaint stating that the insurer M/s LIC of India had wrongly repudiated death claim preferred by her on the sudden death of her husband. While the insurer contends that the claim had been rightly repudiated by them on the basis of evidence gathered in respect of treatment undertaken by the insured for Grade -2 esophageal varices and Congestive gastropathy, prior to the date of proposal. Her appeal for a review of the repudiation decision to the Zonal Office Claims Dispute Redressal Committee of the insurer has been rejected. Hence the complainant approached this forum for settlement of the claim by the insurer. 18) Cause of Complaint: Repudiation of death claim by the insurer. a) Complainants argument: In her complaint letter dated 8.9.2020, the complainant

submitted that her husband took insurance policy number 607130562 from LIC of India for Rs.500000 sum assured commencing from 19.1.2018. Complainant stated that her husband had taken treatment for stomach pain. After taking treatment and medicines, her husband was normal and was back to agriculture work. He expired due to heart attack on 7.9.2018 at home. Complainant’s appeal to the Zonal Claims Review Committee has been rejected .Thus the complainant pleaded for intervention of this forum for settlement of the claim by the insurer. b) Insurer’s argument: In its self contained note dated 25.9.2020, the insurer submitted that policy was issued on the life of K Ramesh on 19.1.2018 and it resulted into death claim on 7.9.2018. During investigation it is found that DLA was diagnosed on 9.10.2017 as per the PNR Gut and liver clinic with Grade 2 esophageal varices and congestive gastropathy which is result of chronic alcoholic liver disease i.e. cirrhosis of liver. The above information was material for assessing and accepting the risk. Had the life assured mentioned the information in proposal, additional reports like Liver Function Test, Endoscopy report, biopsy report of liver would have been called for considering the risk? Since the above treatment was prior to the date of proposal the claim was repudiated under Sec45 of insurance act 2015.The insurer stated that the claim had been rightly repudiated by them on the basis of evidence gathered in respect of treatment undertaken by the insured prior to the date of proposal. Thus the insurer pleaded for dismissal of the complaint by this forum. 19) Reason for Registration of Complaint:- Scope of the Insurance Ombudsman Rules-2017: Any partial or total repudiation of claims by the life insurer, general insurer or the health insurer. 20) The following documents were placed for perusal. a) SCN dt.25.9.2020 b) Complaint letter dated 8.9.2020 c) Repudiation letter dt.20.9.2019 d) Copies of Policy Schedule & Proposal 21) Result of hearing with both parties (Observations & Conclusion) :

Pursuant to the notices issued by this office, both the parties attended the on line hearing held at Hyderabad on 9.10.2020. During the hearing, the complainant repeated the contentions of her complaint. On the other hand, the representative of the insurer who attended the hearing argued that the deceased life assured had intentionally suppressed material information about his health condition with a fraudulent intention.

On careful consideration of the written and oral submissions of both the parties and the documentary evidence adduced, it is evident that the deceased life assured had taken treatment from 9.10.2017 as per the PNR Gut and liver clinic for Grade 2 esophageal varices and congestive gastropathy prior to date of proposal 19.2.2018 . As per the OP card of PNR GUT and liver clinic dated 9.10.2017, doctor has prescribed the following test: upper GI Endoscopy report which reveled DLA suffered from Gr II Varices of oesophagus and congestive gastropathy of stomach . Esophageal varices are abnormal, enlarged veins in the tube that connects the throat and stomach (esophagus). This condition occurs most often in people with serious liver diseases. Gastritis is inflammation of the lining of the stomach due to use of certain pain relievers and drinking too much alcohol also contributes to gastritis. DLA was prescribed following medicines: Librium 25 Tablet to treat severe anxiety. Alcomax Tablet to correct thiamine deficiency in chronic alcoholics. Usibon 300 Tablet is to dissolve certain types of

gallstones, to prevent them from forming and to treat a type of liver disease called primary biliary cirrhosis. Stn 10mg Tablet for lower cholesterol and to reduce the risk of heart disease and Ultra Plus Tablet for pain relieving for 10 days as per the prescription.

The DLA knowing well about his health conditions, choose not to disclose these material facts with a fraudulent intention and took the policy in 19.1.2018 for sum assured Rs. 5 lakhs with in three month from diagnoses of disease i.e. 9.10.2017.The policy resulted into death claim on 7.9.2018 within 7 month 18 days from commencement of risk. Had the DLA disclosed the said material information about his health in proposal, the requirements and the underwriting decision would have been different. In Declaration of Good Health there were questions like –consulted medical practitioner for any ailment, admitted in hospital nursing home for general check up, for observation, treatment or operation? Are you suffering from or have you suffered or undergone investigation or treatment for ailment pertaining to liver, stomach, heart, lungs, kidney, brain or nervous system, for all these columns in the proposal dt. 19.1.208 ,DLA has noted as “NO”. For question what has been your usual state of health. DLA has stated “ GOOD”. The above information was material for assessing and accepting the risk. Had the life assured mentioned about the treatmrnt in proposal, additional reports like LFT( Liver function tests) , Endoscopy report, biopsy report of liver would have been called for considering the risk. DMR of LIC has opined that DLA was chronic alcoholic and treated for oesophageal varices and cirrhosis of liver. Insurance company has alleged suppression of material information in respect of answers given by life assured under column in personal history regarding his health. As per claim enquiry report of the insurer ,DLA was sick and had taken treatment for heart problem but IO could not produce treatment particulars. Deceased insured had concealed facts with respect to the state of his health which had influenced the decision of the insurer on question as to whether the insurance cover should be granted to him or not. It is quite possible that had his past ailment and treatment been disclosed by the deceased, insurance cover would have been refused to him.

It is clearly evident that even though the insured had been suffering from the said ailments much prior to proposal, he did not disclose the same in the proposal and obtained the insurance policy with fraudulent intention. Life assured expired at the age 38 years. Affidavit was submitted to the insurance company in lieu of medical & hospital treatment form. The contract of insurance is one of ‘utmost good faith’ and both parties to the contract shall disclose all facts, whether material or not, in full, to the other. Since the life assured did not disclose his correct status of health in his proposal for insurance, the insurer cannot be made liable to pay the sum assured. Concealment of material fact amounts to fraud. Accordingly the claim was rightly repudiated by the insurer. Therefore the Forum comes to the conclusion that there was suppression of material facts at the time of obtaining the said policy and hence the insurer is justified in repudiating the death claim on the said policy and the decision of insurer does not warrant any intervention. Hence, the complaint is treated as dismissed.

AWARD In the light of the evidence on record, it is observed that the repudiation of the claim by the Insurer being in consonance with the terms & conditions of the policy and the general principles of insurance, it does not warrant any interference at the hands of the Ombudsman. In result, the complaint is dismissed.

22) The attention of the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules, 2017: d) According to Rule 17(6) the insurer shall comply with the award within 30 days of the receipt

of the award and intimate compliance to the same to the Ombudsman.

e) According to Rule 17(7) the complainant shall be entitled to such interest at a rate per annum as specified in the regulations, framed under the Insurance Regulatory & Development Authority of India Act from the date the claim ought to have been settled under the Regulations till the date of payment of the amount awarded by the Ombudsman.

f) According to Rule 17 (8) the award of Insurance Ombudsman shall be binding on the Insurers. Dated at Hyderabad on the 12th day of October 2020

(I.SURESH BABU)



PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, MUMBAI (MUMBAI METRO & GOA)

(Under rule no. 16(1)/17 of the insurance ombudsman rules, 2017)

OMBDUSMAN: – SHRI MILIND KHARAT Complaint No: MUM-L-019-2021-0121

Award No: IO/MUM/A/LI/ 00 /2020-21 Complainant: Mrs. AfsariMasoomKhan

Respondent: HDFC Standard Life Insurance Company Ltd

1. Name and address of the complainant Mrs. AfsariMasoom Khan, Mumbai

2 Policy No. 19995925

3 Name of Insured Late Mr. Masoom Ahmed V. Khan

4 Date of Birth 01.07.1966

5 Name of the Insurer HDFC Standard Life Insurance Company Ltd;

6 Date of Commencement 17.01.2018

7 Plan & Term/ Premium paying term HDFC Life SL Pro Growth Flexi

8 Premium, Mode Rs.2,00,000/-, Yearly

9 Maturity Sum Assured Rs.14,00,000/-

10 Date of first letter from company 18.05.2018

11 Reply from GRC 18.05.2018

12 Date of receipt of the complaint at

Ombudsman office

18.03.2020

13 Nature of Complaint Repudiation of Death Claim

14 Amount of relief sought Rs.14,00,000/-

15 Complaint registered under

Ombudsman Rules, 2017

13 /1(c)

16 Date of hearing/ place 26.10.2020, at 10.45 am, Mumbai

17 Representation at the hearing

a) For the Complainant Mrs. AfsariMasoom Khan

b) For the Insurer Mr. Chinmay V. Sawant

18 Complaint how disposed By issuing the Award

19 Date of Award 28.10.2020

Brief Facts of the Case: Mr. Masoom Ahmed V. Khan had taken the policy bearing no.

19995925 from the HDFC Standard Life Insurance Company Ltd. under HDFC Life SL Pro Growth

Flexi Plan on 17th January, 2018 for a premium paying term of 10 years with Rs.14,00,000/- Sum

Assured. The Life Assured (DLA) expired on 21.02.2018. Mrs. AfsariMasoom Khan, his wife and

nominee under the policy lodged Death Claim with the Insurance Company. The Insurance

Company deducted the charges towards medical, agents commission, stamp charges etc and

credited Rs.1,75,000/- to her bank account and repudiated the claim vide letter dated

18.05.2018. The Complainant is not agreeable to the decision of the company and requested

the Forum to direct the Insurance Company to pay the death claim for full sum assured.

Contentions of the complainant: Mrs. AfsariMasoomKhan appeared and deposed before the

Forum on video call conference in the joint hearing with the company on 26th October, 2020.

The Forum asked the complainant reasons for her grievance. The complainant stated that her

husband had purchased the above policy for Rs.14 lakhs sum assured. She submitted that her

husband was running a wedding concepts business whichis an event decoration company. He

died due to heart attack in his room at Holiday in a Hotel at Goa. She submitted that he was not

having any history of heart ailment. In the year 2017, on 12th February 2017 ,he was admitted

to KokilabenDhirubhaiAmbani Hospital for the treatment for vomiting and pain in abdomen and

got dischared on 16th February 2017.

The Respondent repudiated the death claim on the ground that the complainant was a k/c/o

HTN for 10 years and Dyspepsia for 5 years which was not disclosed in the proposal form at the

time of inception of the first policy.

The complainant is not satisfiedwith decision of the Company and requested the Forum to

intervene and set aside repudiation made by the respondent.

Contentions of the Respondent: The Forum asked the Company the reasons for repudiation of

above claim, the Company's official Mr. ChinmaySawant,from legal department of the

Respondent Company submitted that the available documents and internal investigation

revealed that the patient is a k/c/o HTN for 10 years and Dyspepsia for 5 years which was prior

to inception of the policy and the insured had not disclosed the said history in the proposal

form. It is also pertinent to note that the DLA died almost within a month of issuance of the

subject policy which was indicative of the GLA suffering from past medical history ,as evidence.

Had the DLA made disclosures truthfully, the Insurance Company would not have issued the

policy or ,ifat all, they would have issued after charging higher extra premium. Hence,the claim

stood repudiated for non-disclosure of material facts as per policy terms and condition.

However, company refunded the balance premium of Rs.1,75,000/- after deducting the initial

expenses towards medical, stamp charges and agents commission.

Observations of the Forum:On perusal of depositions made by both the parties and the

documents produced on record, it is observed that the company repudiated the claim on the

ground that complainant had a history of HTN for 10 years and Dyspepsia for 5 years which

was prior to inception of the policy. The Forum also observed that the DLA died almost within a

month of issuance of the subject policy.

In Insurance contracts where one party alone possesses full knowledge of all the material facts,

the law requires him/her to show uberrima fides and must disclose all the material facts known

to him/her, otherwise the contract may be rescinded.

In the present case, the life assured had given incorrect statements; which misled the Insurer to

issue the policy. Had the life assured disclosed his past illness and other details, it would have

certainly affected the Insurer’s underwriting decision. Thus, the life assured has denied the

Insurer an opportunity of correct assessment of risk.

Therefore, the Forum is of the opinion that the decision of the Insurer to repudiate the death

claim on this ground is fair and justified. Hence the following order:

AWARD

Under the facts and circumstances of the case, the complaint lodged by Mrs. AfsariMasoom

Khan against HDFC Standard Life Insurance Co. Ltd. does not sustain.

It is particularly informed that in case the award is not agreeable to the complainant, it would

be open for him/her, if he/she so decides to move any other Forum/Court as he/she may

consider appropriate under the Laws of the Land against the Respondent Insurer.

Dated: This 28th day of October, 2020 at Mumbai.

(MILIND KHARAT)

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, MUMBAI (MUMBAI METRO & GOA)

(UNDER RULE NO. 16(1)17 OF THE INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN – SHRI MILIND KHARAT

Complaint No.: MUM-L-029-2021-0151 Award No: IO/MUM/A/LI/OO /2020-21 Complainant: MsMeenaSurindraGhogalia Respondent: LIC of India

Name and address of the complainant MsMeenaSurindraGhogalia , Mumbai

Policy No. 907384125,892167391,892304715

Name of Insured, DOB, Age at Proposal Late Shri SurindraTeluGhogalia,

31.8.1974 25yrs,36 yrs,40 yrs

Name of the Insurer LIC of India

DOC 1.10.1999,1.2.2011,1.1.2015

Date of Death 5.12.2016

Plan and term 108-25(18) ,14-21,814-18

Premium, Mode 665, 3317,748.50 All Monthly (sss)

Sum Assured 1 Lac,8 Lacs,1.5 Lacs

Date of first complaint to GRO 26.08.2018

Date of receipt of the complaint at OIO 16.07.2019

Nature of Complaint Double Accident claim rejected

Amount of relief sought Double Accident claim amount

Rule of Insurance Ombudsman Rules, 2017

under which the complaint was registered

13(1) (b)

Date of hearing/ place 14.10.2020 / Mumbai

Representation at the hearing

a) For the complainant MsMeenaSurindraGhogalia

b) For the Insurer Smt. KajalGolani

Complaint how disposed By issuing the Award

Date of Award 16.10.2020

Contention of the complainant:

The complainant stated that her husband purchased the above policies wherein LIC had settled

the basic claim under all 3 policies but regreted Double Accident Benefit Claim. Late Mr.

Surendra was working as Cabin Assistant in Air India. He was not having any addiction. He was

having Depression but no other major illness. On 5.12.2016 at about 7.30A.M.he went for

morning walk in the colony. A car washing boy intimated that Surendra was lying on the ground

near building number 16 in Air India colony. When the complainant (wife of the deceased) went

to see him, she found him lying on the ground and had head injury. Immediately,he was taken

to the hospital where Doctor had declared him dead. Then dead body was taken to cooper

hospital for Post Mortem. she approached the Company for the claim amount but only basic

claim was settled and Double accident claim was rejected. SBI General Insurance company Ltd.

had settled the accident claim for 10 Lacs under policy number 150420-0000-00. She has

requested the Ombudsman to help her to get her Double Accident claim amount.

Contentions of the Respondent:

The Respondent contended that the Deceased Life Assured died due to Cerebral Compression

as Result of Craniocerebral Trauma (Unnatural)as per Final Verdict.

1. As per Police inquest and ADR no 135/16, Deceased had gone for walk on 5.12.2016 and was

found lying unconscious and sustained head injury.

2. As per treatment certificate submitted,Deceased Life Assured had been suffering from major

depression disorder disease and treatment was given for acute stress disorder from 18.11.2016

to 25.11.2016 ( DrSunita Khan – Air India Medical Department)

3. As per Discharged summary received from Kohinoor Hospital, Date of admission was

15.11.2016 and date of Discharge was 17.11.2016. DLA was diagnosed with major Depression

Disorder and was advised 24*7 supervision of relatives due to increased stress and was advised

for supervised medication. Deceased Life Assured was treated with anti-depressants.

4.Final Verdict received, categorising death as unnatural (and not accident) due to cerebral

compression,as result of craniocerebral trauma.

5.As per Jawab given by wife and son of Deceased Life Assured, DLA had availed loan and was

under tension and was taking medicines. Deceased Life Assured might have giddiness and felt.

6.As per policy conditions,Accident means a sudden, unforeseen and involuntary event caused

by external, visible and violent means.

7.In view of above facts, available evidences and as per policy conditions death does not appear

to be due to accident. Case was put up to DODRC and as per decision of the Competent

Authority DAB claim was not payable under above policies.

Observations and conclusions:

The forum observed that

1. LIC has regretted the Double accident claim on the basis of policy conditions: “ to pay an additional sum equal of the sum assured under the policy if the life assured

shall sustain any bodily injury resulting solely and directly from the accident caused by

outward, violent and visible means and such injury shall within 120 days of its

occurrence solely, directly and independently of all other causes result in the death of

the life assured” In this case it is presumed that DLA died due to existing illness of

depression which is internal.

2. It is observed that SBI General Insurance company Ltd. had settled the accident claim for 10 Lacs under policy number 150420-0000-00 ( vide letter dt 16.8.2018)

3. On 28.9.2018, Divisional Medical Referee of LIC opined that death can be considered as Accident as per the records.

4. Certificate received from Kohinoor Hospital dt 25.11.2016 (Dr. Sajid Ali Khan, Psychiatrist) stated “Mr. Surendra T. Ghogalia was indisposed from 14.11.2016 to 24.11.2016. He was suffering from Depressive Disorder. He has recovered and is fit to resume duties from 25.11.2016”

5. Medical Certificate submitted by the claimant dt 25.11.2016 issued by Air India Medical Services Department stated that Deceased Life Assured was fit to resume work from 25.11.2016.(fit to work under supervision only) (Certificate given by Dr. MakarandSolage)

6. As per Jawab given by the complainant (wife of Deceased Life assured),Mr. Surendra was regularly attending the office.

7. The Respondent could not produce any evidence in support of their contentions that the death was not due to an accident and it occurred due to internal disease of Depression only. In view of all the above, it was obvious that the life assured had sustained bodily injury

due to fall while taking morning walk resulting solely and directly from the accident to

which he succumbed.

This Forum notes that the case on hand attracted none of the Exclusion clauses

enumerated in paragraph (b) (i) to (v) of “Conditions & Privileges” of the Accident

Benefit of the policy. This being so, the complaint is tenable and complainant is entitled

to Accident Benefit Sum Assured also.

The award is as follows:

AWARD

Under the facts and circumstances of the case and the submissions made by both the parties,

the Insurer is directed to consider and settle the Accident Benefit claim under all three

policies (Nos. 907384125, 892167391, 892304715) for the eligible amount as per terms and

conditions governing the policies.

It is particularly informed that in case the award is not agreeable to the complainant, it would

be open for her, if she so decides to move any other Forum/Court as she may consider

appropriate under the law of the land against the Respondent insurer.

The attention of the Insurer is hereby invited to the following provisions of the Insurance

Ombudsman Rules, 2017:

a. As per Rule 17(6) of the said rules the Insurer shall comply with the award within thirty days

of the receipt of the award and intimate compliance of the same to the Ombudsman.

b. As per Rule 17(8), the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Mumbai, this 16th day of October 2020

(Milind Kharat)

INSURANCE OMBUDSMAN, MUMBAI

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN,

MUMBAI (MUMBAI METRO & GOA)

(UNDER RULE NO. 16(1)/17 OF THE INSURANCE OMBUDSMAN RULES, 2017)

OMBDUSMAN – SHRI MILIND KHARAT

Complaint No : MUM-L-029-2021-0154

Award No: IO/MUM/A/LI/ 00 /2020-21

Complainant: Mrs. BasantiShivkumar Sharma

Respondent: LIC of India, Thane Divisional Office .

1. Name and address of the complainant Mrs. BasantiShivkumar Sharma,

Mumbai

2 Policy No. 910650582

3 Name of Insured Late ShivkumarRajaram Sharma

4 Name of the Insurer Life Insurance Corporation of India,

Thane Division Office

5 DOC 17.07.2018

6 Total Sum Assured Rs. 7,00,000/- with AB,Rider

7 Policy Table & Term/ Premium paying

term

836/16/10,

8 Plan LIC’s Jeevan Labh

9 Date of Death 24.10.2019

10 Date of repudiation of AB 19.03.2020

11 Duration of the policy from DOC 07 Days 03 Months & 1 year

12 Date of reply from GRC 31.01.2020

13 Date of receipt of the complaint at OIO 24.07.2020 & 22.09.2020

14 Nature of Complaint Repudiation of AB Rider claim

15 Amount of relief sought Requested for 7,00,000/-.

16 Complaint registered under

Ombudsman Rules, 2017

13 (1) (e).

17 Date of hearing/ place 19.10.2020, at Mumbai


a) For the Complainant Mrs. BasantiShivkumar Sharma

b) For the Insurer Mrs.Neelima S. Naravane,

(Manager-Claims Thane D.O.)

19 Complaint how disposed By issuing the Award


Brief Facts of the case:Deceased Life Assured (DLA) Mr. Shivkumar R. Sharma had taken a policy

from Life Insurance Corporation of India, bearing no. 910650582 with date of commencement

being 17.07.2018 under Jeevan Labh Plan for accidental Rider Sum Assured of Rs.7,00,000/- .

He expired on 24.10.2019. Mrs. BasantiShivkumar Sharma, his wife and nominee under the

policy lodged Death Claim with the Insurance Company. The Insurance Company settled basic

sum assured of Rs.7 lacs and repudiated the Accidental Benefit Rider claim and conveyed to the

complainant vide its letter dated 19.03.2020. Hence,the complaint was filed before the Forum.

Contentions of the complainant: Contention of the complainant: The complainant stated that

her husband purchased the above policy for Rs.7 lakhs sum assured. She submitted that her

husband was running a plywood shop at Andheri and was a very simple shopkeeper with always

having a sober nature and was never involved in any kind of violent activities and had no

criminal background. Her husband expired ofstabbing on 09.10.2019 i.e (unforeseen accident

happened with her husband). The Insurance Company settled the basic sum assured of Rs.7 lacs

on 19.03.2020 and rejected Accidental Benefit Rider claim.

She approached the Company for the claim amount but the same was rejected on the ground

of it being a Murder Simpliciter. They are not agreeable to the decision of the Company and

requested the Forum to intervene and ensure justice in the instant case.

Contentions of the Respondent: The Forum asked the Company the reasons for repudiation of

above claim. The Company's official Mrs. Neelima S. Naravane, Manager Claims from the

Respondent Company submitted that the Deceased Life Assured (DLA) was running a plywood

shop at Andheri. Mr. Pappu having a business of Chinese food handcart started his operation in

front of DLA’s shop.DLA had told him not to keep the cart in front of his shop.This resulted into

quarrel between them as per newspaper information. The matter was reported to the Police

that took action for removing the cart. Pappu got infuriatedat this and stabbed DLA ON

09.10.2019 as per Jawab.DLA was hospitalized and succumbed to injuries on 24.10.2019. Based

on above facts, the Respondents admitted Early Death Claim of Basic Sum Assured and rejected

Accident Benefit Rider treating it as Murder Simplicitor as per Circular CO/CRM/607/23 dated

15.10.2007.

Observations and Conclusions: On analysis of the case, it is observed that the subject claim has

been repudiated by the Respondent on the ground of Accident Benefit Rider treating it as

Murder Simpliciter.

The forum observed that the above policy was purchased by the deceased life assured for sum

assured of Rs.7 lakhs with accident benefit rider. He died as he was stabbed while going to his

home. As per CO/CRM /607/23 circular dated 15th October, 2007 content in page no.1 para

no.3 stated that “ It may be pointed out here that each case materially differs from the other

and therefore no specific situation can be taken for fixed guidelines for which no definite

instructions can be made applicable uniformally/universally in all cases. Each case has to be

judged and decided on its merit.” As far as the DLA is concerned the stabing incidence was an

accident. In absence ofcontrary evidence from the Respondent and considering the fact that

the Life Assured died due to accident injury, the complaint is tenable and the award follows as

under:

AWARD

Under the facts and circumstances of the case, the Life Insurance Corporation of India is

directed to pay the Accident Benefit Rider under the policy bearing number 910650582 to

Mrs. BasantiShivkumar Sharma. There is no order for any other relief.

The attention of the Complainant and the Insurer is hereby invited to the following provisions

of the Insurance Ombudsman Rules, 2017:

a) As per Rule 17(6) of Insurance Ombudsman Rules, 2017, the insurer shall comply with the award within thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman.

b) As per Rule 17(8) the award of Insurance Ombudsman shall be binding on the Insurers.

c) It is particularly informed that in case the award is not agreeable to the complainant, it would be open for him/her, if he/she so decides to move any other Forum/Court as he/she may consider appropriate under the Laws of the Land against the Respondent Insurer.

Dated: This 28th day of October, 2020 at Mumbai.

(MILIND KHARAT)

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE

(STATE OF MAHARASHTRA EXCEPT MUMBAI METRO)

UNDER SECTION 16(1)/17 OF THE INSURANCE OMBUDSMAN RULES-2017 OMBUDSMAN– VINAY SAH

CASE OF Smt. JAGRUTI J DAMANI V/S L.I.C. OF INDIA

COMPLAINT NO: PUN-L-029-1819-389

Award No IO/PUN/A/LI/ /2020-21

1 Name Address of Complainant

Smt. Jagruti J. Damani Navi Mumbai

2 Policy No. Type of Policy

885880725 LICs Jeevan Akshay VI (Single Premium) Policy

3 Date of Proposal Date of Commencement Date of First Annuity Mode Annuity Amt. Annuity Option

26 02.2017 27.02.2017 27.02.2018 YLY 21585.00 “F”Annuity for Life & return of Purchase Price on death

4 PPT Premium Date of death

189 Rs 300000/ 19.12.2017

5 Insurance Intermediary Agent

6 Name of Insured Age Name of Policy holder

Smt.Dayamanti M shah 75 Smt Dayamanti M Shah

7 Name of Insurer LIC OF INDIA

8 Nature of Complainant Interest on Purchase price not paid after death of Annuitant.

9 Relief sought Interest on Rs.300000 from 27.02.17 to 19.12.2017

10 Date of First Complaint to Insurer Date of Representation to GRO Date of refusal by RI

17.01.2018 22.02.18 28.03.2018

11 Reason for Rejection Payment as per T/C of Policy

12 Date of receipt of Complaint to OIO

16.10.2018

13 Rule under which the Complaint was registered

13(1)(d)

14 Date of hearing/Place Online hearing on 6.10.2020 from Pune


A)For the Complainant Smt Jagruti Damani

B)For the Insurer Smt.Shilpa Mhapsekar

16 Complaint how disposed Dismissed.


18) Brief History of the case:-

Complainant is the first Nominee under LICs Jeevan Akshay (Single Premium) policy purchased

by Deceased LA Smt. Damayanti Shah on 27.02.2017 by investing Single Premium of

Rs.300000/- LA died on 19.12.2017. LIC returned Rs.300000 invested but did not pay interest

for the period till death from the date if investment.

19) Contentions of the Complainant:

The Complainant contends that they had invested an amount of Rs. 3L in Jeevan Akshay VI

pension scheme of RI (Respondent Insurer). In order to get good interest, they chose yearly

mode. Unfortunately, her mother (Life Insured) expired after 10 months from policy issuance.

She was not informed by the agent or the company that in such a situation, they will not get

any interest. After her mother’s death, she was paid only the principal amount 3L. She

contacted RI many times asking for interest but they refused for it. Aggrieved, she has

approached Ombudsman Forum praying for justice as she is a widow and it is not her fault.

20) Contention of Respondent Insurer (RI):

RI in their SCN have submitted that under the said policy, the annuitant (Complainant’s mother)

had opted for yearly mode of payment. As the policy commencement date was 27.02.2017, the

first instalment of annuity of Rs. 21585/- was to start from 27.02.2018. The annuitant died

before this due date. In such situation, as per the conditions mentioned explicitly on the first

page of the policy document, no proportionate annuity is payable from the date of

commencement (27.02.2017) to the date of death (27.02.2018).

The said condition reads as “But where the annuity ceases or determines on the death of

annuitant, no part of the said annuity shall be payable or paid for such time as elapse

between the date of payment immediately preceding the death of annuitant and date of

his/her death.”

Request of complainant for proportionate annuity is totally unjustified and is in contravention

of terms and conditions of policy document.

As such the complaint may be dismissed.

21) Reason for registration of Complaint:-

The complaint falls within the scope of Insurance Ombudsman Rules, 2017 and so it was

registered.

22) Following documents were placed for perusal:-

1) Complaint, copy of policy document and correspondence.

2) Consent of complainant in Annexure VI A

3) SCN along with consent from the Respondent Insurer and copy of proposal

form.

23) Observations and conclusions:-

During the online hearing on 6.10.2020 from Pune, both the parties reiterated their earlier

submissions. It is observed as under:-

The said annuity policy was chosen with option ‘F’ i.e. Annuity for life and return of

purchase price on death. Accordingly, RI has returned the purchase price Rs. 3L. There is

no dispute on this point.

The annuitant had chosen yearly mode for higher returns. Unfortunately, she died

before completion of one year from commencement. Annuity was yet to start.

As the invested amount was sizeable and it was lying with the RI for 10 months, it was

not wrong on the Complainant’s part to demand interest for the said period.

However, as pointed out by RI, and verified by Forum, there is no provision to pay

proportionate annuity. There is clear mention of this clause in the policy document.

Complainant to note that this eventuality was bound to happen at some point of time.

The rules regarding the annuity payment being what they are, the only way to minimize

losses is choosing the annuity mode with higher/highest frequency even if the returns

are little less.

Though the Forum has full sympathy both for monetary loss and loss of life too, in this

case, the ruling cannot be given in favour of the Complainant.

AWARD Taking into account the facts and circumstances of the case and submissions made by both the parties during the course of hearing, the complaint does not sustain and hence dismissed.

Dated at Pune, on this 9th day of October, 2020

VINAY SAH

INSURANCE OMBUDSMAN

PUNE


STATE OF MAHARASHTRA EXCEPT MUMBAI METRO

(UNDER RULE NO: 16 ( 1 ) /17 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN - VINAY SAH

Case of Ms. Nanubai Jeevan Admane v/s Life Insurance Corporation of India

Complaint No: PUN-L-029-1819-281

Award No: IO/PUN/A/LI/ /2020-2021


Ms. Nanubai Jeevan Admane Kolhapur

2. Policy No. & Type of Policy 947848289- Jeevan Rakshak

3. Date of Com. Risk/ Prop. Dt. 22.10.2016, (20.10.2016)

4. Term/PPT & Premium Amount Death Sum Assured

20/20, Rs.528/-, Mly. Rs.175000/-

5. Date of Death Date of Risk Duration Cause of Death

18.04.2017 22.10.2016 5Mths 27D Raised ICT in case of Left Myocardial Infraction

6. Name of the Insured Name of the Policyholder

Mr. Jivan B. Admane (Deceased) Mr. Jivan B. Admane

7. Name of the Insurer Life Insurance Corporation of India


9. Relief sought Payment of death benefits

10. Date of rejection by Insurer 31/10/2017

11 Date of rejection by GRO(ZO) 27/04/2018


13. Rule of I O under which the Complaint was registered

13 (1) (b)

14. Date of hearing & Place Online hearing 28.10.2020 (through video conferencing)


a) For the Complainant Self

b) For the Insurer Mr. Sanjeev Nigudkar


17. Date of Award 28.10.2020

17) Brief details of the Case:-

The policy was purchased by the Deceased LA from RI. The risk was commenced on

22.10.2016. LA died within 6 months from the commencement of risk. The death benefit

claimed by the complainant, being the nominee under policy, was repudiated by the RI on the

grounds of non-disclosure of illness and treatment taken prior to date of proposal 20.10.2016.

The complainant approached to the GRO of RI (ZO) but the decision of repudiation was upheld.

Hence the complaint.

18) Contentions of the Complainant: -

The Deceased LA was working as Cleaner in Grampanchayat Yadrav.

The LA died due to heart attack.

Death benefit under the policy was repudiated by the RI and the decision of repudiation

was upheld by GRO (Z.O CDRC) also.

The complainant is from economically weak category having small kids. Her husband has

taken only this insurance policy for future provision for the family. The death benefit

was the only source as her financial support.

Hence she approached the forum for relief of getting the death benefits.

19) Contentions of the Respondent:-

The claim is very early i.e within 6 months from the commencement of risk under the

policy in complaint.

The LA died due to Raised ICT in the case of LT Myocardial Infarction. Investigation was

carried out being a very early claim as per applicable provisions of Section 45 of

Insurance Act 1938.

RI has submitted SCN along with the copies of various documents including copy of

proposal form, policy, DO-DRC note and Discharge Summary of Niramaya Hospital,

Ichalkaranji with date of admission as 06.06.2016 and date of discharge 11.06.2016 with

diagnosis of Acute Coronary Syndrome with ST ELEVATION IWMI

The DLA had the history of convulsions and was alcoholic also as per IPD case paper of

Niramaya Hospital, Ichalkaranji, dt 16.04.2017.

All the said history of illness goes prior to date of proposal 20.10.2016. Hence the claim

was repudiated by RI on the ground of suppression of material facts on 31.10.2017. RI

has sent repudiation letter dated 31.10.2017 to claimant informing regarding

repudiation of claim on grounds of suppression of material facts .In the letter RI has

mentioned that premiums amounting to Rs 3168/- are being refunded to the claimant

towards full and final payment.

ZO CDRC has upheld the decision of repudiation on 27.04.2018.

20) Reason for registration of complaint: - The complaint falls within the scope of Insurance Ombudsman Rules, 2017 and so, it was registered.

21) The following documents were placed for perusal: - 1. Complaint, copy of policy document and correspondence. 2. Consent form in Annexure VIA & VIIA. 3. SCN from the Respondent Insurer along with the copies of relevant documents. 4. Niramay Hosp. discharge card

22) Observations & Conclusion:-

A hearing was conducted on 28.10.2020 through video conferencing. During hearing the complainant and the representative of RI reiterated their earlier submissions. The forum has the following observations to make:-

The DLA died within 6 months from date of risk due to Raised ICT in case of Left Myocardial Infarction.

It is a very early claim as per provisions of Section 45 of Insurance Act 1938 and hence investigation was done by RI.

The claim was repudiated due to suppression of material facts on 31.10.2017.

RI, in support of the decision of repudiation, has submitted the Discharge card of Niramaya Hospital, Ichalkaranji, where DLA was admitted from 06.06.2016 to 11.06.2016 for Acute Coronary Syndrome with ST elevation IWMI.

The RI has also submitted to the forum the case papers of Niramaya Hospital in which it is clearly mentioned that the DLA was alcoholic and had a history of convulsions.

The said history of illness was not disclosed in the proposal form dated 20/10/2016 thus breaching the principle of Uberrimae Fidei (utmost good faith) in the Insurance contract.

DMR of RI has also opined that the cause of death has nexus to the said non disclosed ailment. If the medical treatment history had been disclosed in the proposal, the RI would have called for the special reports which would have affected the underwriting decision. .

The decision of the RI to repudiate the liability is as per policy terms and condition. As the repudiation was on the grounds of suppression of material facts, as per the provisions of section 45 of The Insurance Laws (Amendment) Act ,2015, the RI has decided to refund the premiums paid Rs 3168/- under the policy towards full and final settlement of your claim. The Forum does not find substance in the complaint.

AWARD Taking in to account the facts and circumstances of the case and submission made by both the parties, the forum is of the opinion that the Respondent Company has acted rightly as per terms and conditions of the Insurance contract in repudiating the claim under Policy no.947848289 and therefore requires no intervention of the forum. Hence the complaint is dismissed. However RI is directed to confirm refund of premium to claimant as per its repudiation letter dated 31.10.2017.

Dated at Pune, 28.10.2020

VINAY SAH INSURANCE OMBUDSMAN,

PUNE





Case of Ms. Nikita S. Kawale v/s Life Insurance Corporation of India




Ms. Nikita S. Kawale Solapur-

2. Policy No. & Type of Policy 999338671, Jeevan Lakshya

3. Date of Com. of Risk 22.04.2016

4. Term/PPT & Prem. & SA 18/15, Rs.75051/- Yly., Rs.10 Lakh (TR 10+AB10)

5. Date of commencement of Risk Date of Death Duration of the Policy Cause of Death

22.04.2016 21.05.2016 29 days only SEPTIC SHOCK as primary and MULTI ORGAN FAILURE as secondary


Sidram D Kawale(decd.) Sidram D Kawale


8. Nature of complaint Death benefits repudiated


10. Date of rejection by Insurer 28.03.2018



13 (1) (b)

13. Date of hearing & Place 05.10.2020, online( through video-conferencing)


c) For the Complainant Nikita Kawale

d) For the Insurer Smt. Neha Godbole


16. Date of Award 09.10.2020


The complainant is a wife of Deceased LA and nominee under the policy. The deceased Shri

Sidram D. Kawale was insured for basic SA Rs.10 L with AB and Term rider of Rs.10 L each. The

date of commencement of risk is 22.04.2016 and DOD is 21.05.2016 i.e. DLA died within 29

days from commencement of risk.

The death benefits under the policy are repudiated by the RI therefore; the complainant has

approached Forum for relief.


The policy was purchased by the deceased in 2016.

The LA died on 21.05.2016. The death claim under the concerned policy was repudiated for suppression of material facts i.e. history of RTA and hospitalization thereof.

The DLA had been operated for Cervical grafting and plating with the history of RTA in 2005.

These operation details might not have been disclosed as the question was asked for treatment during last 5 years while signing proposal on 23.03.2016.

The insurance cover was allowed after obtaining necessary medical reports, tests from authorized doctors/test centers and necessary hazard reports from officials of RI.

The contention is that blame cannot be given to DLA for non-disclosure.

As the claim was repudiated, the complainant approached to the forum for relief.


The RI has mentioned in its repudiation letter (Anx-23) following points:

A. The answers given by the DLA in the proposal form Q. No.11 (a, b, c. & i ) were false.

B. The hospitalization in the Ashwani Sahakari Rugnalaya, Solapur due to RTA from

25.12.2005 to 09.01.2006 and operation on 31.12.2005 was not disclosed by the DLA.

C. The history of Cervical Level operation is also revealed in case papers dated

20.02.2016 of SL Raheja Hospital.

D. The suppression of material facts, which had bearing on the granting of risk, was

clearly done with the intent to deceive the corporation. Hence it has been decided to

repudiate all liabilities and all money received by the corporation stands forfeited.

The decision of repudiation is also upheld by CO-CDRC.


21) The following documents were placed for perusal: - 1. Complaint, copy of policy documents and correspondence. 2. Consent form in Annexure VIA & VIIA. 3. SCN from the Respondent Insurer and a copy of proposal form etc. 22) Observations & Conclusion:-

A hearing was conducted on 05.10.2020 through video conferencing. During hearing the complainant and the representative of RI reiterated their earlier submissions.

The Forum after perusal of the records placed before it and after deliberations with the complainant and representative of RI has observed as follows:-

The DLA died within 29 days from date of risk and being a early claim as per provisions of Section 45 of the Insurance Act 1938, investigation was done by RI. The RI has the evidence to prove the non disclosure of the past illness and hospitalization in the proposal form.

The claim was repudiated due to suppression of material facts pertaining to DLAs” hospitalization in Ashwini Sahakari Rugnalay, Solapur for RTA c/o Head Injury. As per the IPD cases papers of the Hospital (IPD No.32889) the DLA was admitted from 25.12.2005 to 09.01.2006 and operated on 31.12.2005 for Cervical grafting and plating. The DLA failed to disclose this information in proposal dated 23.03.2016.

The history of cervical operation 5 years back is also revealed in the case papers of SL.Raheja Hospital, Mumbai dated 20/05/2016.

RI has submitted all the above evidences to the forum which clearly show that the above medical and treatment history prior to the date of proposal was not disclosed in the proposal form dated by DLA which he was bound to disclose as it was suppressed by DLA the principle of Uberrimae fidei (utmost good faith) is breached.

The DMR has opined that the cause of death has nexus to non-disclosure of medical history.

During the hearing the representative of RI has told that having declared history of operation in 2005, the RI would have called additional special medical reports and case would have underwritten either with extra or declined.

RI in its repudiation letter dated 30/11/2016 has mentioned that the suppression of material facts by DLA was clearly done with intent to deceive the Corporation. The forum does not find any substance in the complaint.

AWARD

Taking in to account the facts and circumstances of the case and submission made by both the parties, forum is of the opinion that the Respondent Company has acted rightly in repudiating the claim under policy no.999338671 as per terms and conditions of the Insurance contract and therefore requires no intervention of the Forum. Hence the complaint is dismissed.


VINAY SAH INSURANCE OMBUDSMAN

PUNE



UNDER SECTION 16(1)/17 OF THE INSURANCE OMBUDSMAN RULES-2017 OMBUDSMAN–VINAY SAH

CASE OF Omkar Laxman Bharambe V/S LIC of India.



1 Name & Address of the Complainant

Omkar Laxman Bharambe Jalgaon


958593845 LIC’ New Bima Gold Plan

3 Date of Commencement FUP Mode DOD Duration Duration for DAB Rider claim

28.3.2013 28.3.2016 (28.9.2015 paid on 04.02.2016) HLY 16.08.2016 3Year 4 Month 16days 4 month 18 days from FUP date 28.3.2016.

4 PPT Premium SA Extended Term Cover Benefit Accident SA

179/20/20Rs.3804.00Rs.200000 Rs.100000 Rs.200000

5 Insurance Intermediary LIC agent


Suresh Omkar Bharambe, 33 years Suresh Omkar Bharambe


8 Nature of Complainant DAB OF Rs.200000not paid

9 Relief sought Release of DAB death claim payment Rs.200000

10 Date of First Complaint to Insurer Date of Representation to GRO Date of refusal by RI

01.02.2017 19.12.2017 20.02.2017 /30.01.2018

11 Reason for Rejection Basic claim for Rs.200000 admitted but DAB rider claim Rs.200000 not settled as Policy was not in force


13.03.2018


13(1)(b)

14 Date of hearing/Place 5.10.2020. through video conferencing


A)For the Complainant Asha Nitin Bharambe (Daughter in law of the Complainant)

B)For the Insurer Jayshree Deosthali

16 Complaint how disposed Complaint is dismissed.



Mr Omkar Laxman Bharambe (Complainant) has filed a complaint against Life Insurance

Corporation of India (Respondent) alleging nonpayment of accidental benefit claim.


The complainant has stated that the above policy was taken by his son Mr Suresh Omkar

Bharambe from the respondent company. His son expired on 16.08.2016 in a train accident,

thereafter the death claim was lodged with accident benefit before the RI. RI had paid only the

basic death claim but the accidental benefit claim was rejected. The complainant approached

this forum for payment of accidental benefit claim.


The respondent in their SCN has stated that the policy was in auto cover at the time of death of

DLA and as per the policy condition No. “4‟ accident benefit is not payable during the auto

cover period.



registered.





form, other documents.

23) Observations and conclusions:

During the online hearing held on 5.10.2020 from Pune, both the parties reiterated their earlier

submissions. It is observed as follows:-

The Policy no 958593845 was issued on the life of DLA, Suresh Omkar Bharambe on

28.03.2013 with Half yearly mode of premium in which the nominee is Shri Omkar

Laxman Bharambe, father of the DLA.

The last half yearly premium due on 28.9.2015 was paid on 04.02.2016

As per records submitted to forum the date of the first unpaid premium is 28.03.2016

and as the death of the insured occurred on 16.08.2016, the policy was under auto

cover at the time of death.

The Representative of the respondent has argued that in this case accident benefit is

not payable during auto cover period as per policy condition no. 4.of the said policy

document.

Clause 4 of policy terms & conditions provides that the accident benefit rider will cease

to apply if the policy is in lapsed condition and during the auto cover period the accident

rider shall not be available.

In this case, first unpaid premium date was 28.03.2016, hence policy was in lapsed

condition (auto cover) at the time of death of the insured (Date of death 16.08.2016). So

accident benefit under the policy is not payable as per the above clause.

RI has rightly rejected the accident benefit claim.

AWARD Taking into account the facts and circumstances of the case and submissions made by both the parties during the course of hearing, forum is of the opinion that the RI, in rejecting the accident benefit claim under the policy no.958593845 has acted rightly as per policy terms and conditions of the policy and intervention of the forum is not required. Hence the complaint is dismissed.

Dated at Pune, on this 9th day of October, 2020

VINAY SAH

INSURANCE OMBUDSMAN

PUNE


Smt. Kalindibai D.Suryawanshi v/s Life Insurance Corporation of India


1. Name & Location of the Complainant

Smt.Kalindibai D Suryawanshi, Dombivili Thane

2. Policy No. & Type of Policy 927610556 New Jeevan Anand

3. Dt. of Prop. Dt of Com/ Dt of Com of Risk/SA

01.12.2015 05.12.2015 08.12.2015 Rs.500000

4. Term/PPT & Prm.Amt / Mode / FUP 26 / 26 20393 Yly. 12/2017

5. Date of Death Duration Cause of Death Date of Repudiation Date of rejection GRO

09.02.2017 1Y 2M 4D Hepatitis 26.08.2017 27.04.2018

6. Name of the Insured & Proposer Late Supriya D Suryawanshi

7. Name of RI LIC of India

8 Rep. of RI during hearing Smt N.Naravane


D.L.A Supriya D Suryawanshi had purchased a policy bearing no. 927610556 from the RI. She died on 09.02.2017 and cause of Death was Hepatitis B. The complainant is DLA’s mother and nominee under the policy.

The RI has repudiated the death claim vide its letter dated 26.08.2017, on the grounds of suppression of material facts with the intent to deceive the Corporation

The RI has produced copies of following documents as an evidence of medical history prior to date of proposal dated 01.12.2015:- A. Discharge card of Icon hospital dated 22.08.2008 where diagnosis is mentioned as Juvenile myoclonus epilepsy. B. Prescription dtd 07.10.2008 for CT scan where epileptic seizure is mentioned. C. Case paper from Sheth Shri N.G.Haria Charitable Polyclinic dtd.11.12.2011 stating“k/c/o Epilepsy 1st attack in 2008 and last attack 2 weeks back”. C. Case paper from Sai Jyot Hospital dated 05.02.2017 – H/o epilepsy since childhood not on Rx now. D. Case paper of Nair hospital dated 08.02.2017 mentioning “H/O PTB at the age of 4-5 years, for AKT for 1 yr.”

As per DMR opinion cause of death is due to jaundice and not due to prior medical history. However, on the basis of evidence submitted to forum which is prior to the date of proposal fact remains that the principle of Uberrima fides (utmost good faith) has been breached in the Insurance contract under the policy and suppression of pre existing illness and treatment taken was done with the intent to deceive the Corporation.

AWARD Taking in to account the facts and circumstances of the case and submissions made by both the parties, the Forum is of the opinion that RI in repudiating the claim under policy no.927610556 has acted rightly as per terms and conditions of the Insurance contract and needs no intervention of the Forum. Hence the complaint is dismissed.


VINAY SAH

INSURANCE OMBUDSMAN, PUNE

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, PUNE (STATE OF MAHARASHTRA EXCEPT MUMBAI METRO)


CASE OFSmt Kasturi R Shikhari v/s SBI Life Insurance Co. Ltd



1. Name & Address of the Complainant Smt Kasturi R Shikhari.,Gadhinglaj

2. Policy No. & Type of Policy 1J044552201,Saral Swadhan plus

3. Name of the Insured & Proposer Mr. Annasaheb Ramgonda Shikhari(decd)

4. Name of the Insurer SBI Life Insurance Co Ltd

5 Rep of RI during hearing Sampada Shetty

6. Nature of complaint Death claim not paid


The complainant’s son, Mr. Annasaheb Ramgonda Shikhari, took a policy from the

respondent insurer on 06.05.2016 for a Sum assured of Rs 400000 with a yearly premium of

Rs 5000/-.Unfortunately, the life assured passed away in an accident on 21.09.2018. The

policy was in lapsed condition with FUP 06.05.2018 at the time of death. The complainant

has requested the forum seeking direction to the insurer to settle the death claim. The

respondent insurer has filed the self-contained note. It is submitted that the deceased life

assured took a life insurance policy for a sum assured Rs 400000/- for a term of 10 years.

Yearly renewal premium due on 06.05.2018 was not paid and the policy got lapsed and the

risk was not covered thereafter. Life assured died on 21.09.2018 and as on that date policy

was not in force. Hence as per the terms of the policy insurance death claim is not payable.

It is duly admitted by the complainant in her complaint that the deceased policy holder did

not pay the premium for the due 06.05.2018. RI has sent Renewal premium intimation for

premium due 06.05.18 and lapse intimation on 22.03.2018 and 05.06.2018 respectively.

In view of the above fact and circumstances, the forum notes that the complaint is not

sustainable as the repudiation action of RI is valid and the claim has been rejected strictly as

per the terms and conditions of the policy.

AWARD Taking into account, the facts & circumstances of the case and the submissions made by both the parties during the course of hearing, the forum is of the opinion that RI has acted rightly in rejecting the death claim under the policy no.1J044552201 as per terms and conditions of the Insurance contract. Hence the complaint is dismissed.

Dated at Pune,16.10.2020 VINAY SAH INSURANCEOMBUDSMAN, PUNE


Mr. Rakesh Jagtap v/s HDFC Life Insurance Co. Ltd.


1. Name & Location Mr. Rakesh Jagtap, Nashik

2. Policy No. & Type of Policy 90197549, Health Assure

3. Date of Com. Risk 20.11.2015,

4. Term/PPT & Premium Amount Whole Life-PPT 3 years

5. Name of RI HDFC Life Insurance Co.Ltd

6 RI rep. during hearing Chinmay Sawant

7 Name of the Insured Name of the Policyholder

Mr. Yashwant Jagtap Mr. Rakesh Jagtap

A rehearing was conducted on 28.10.2020 through video conferencing. During hearing

the complainant and the representative of RI reiterated their earlier submissions.

The policy was issued after conducting various tests of the proponent and obtaining

medical reports.

The beneficiary Shri Yashwant Jagtap was admitted for treatment in Sainath

Multispecialty Hospital on 28th July 2016.

The RI has regretted the claim as the history of DM is there for 1 to 1 ½ years which is

prior to date of proposal i.e 19.09.2015.

The complainant has produced a copy of admission papers of Sainath Multispecialty

Hospital in which only DM/HTN is mentioned but no prior history is mentioned.

The complainant has also produced a copy of a certificate dated 30.09.2016 of

consultant Dr. Rushikesh Gangurde from Sainath Multispecialty Hospital in which he has

certified that the beneficiary was diagnosed to have DM in May 2016 (DOC- 20.11.2015)

and he had no history of diabetes in past and was not on any medication.

The letter of repudiation mentions history of DM for one and half years as per papers

from Sainath Multispecialty Hospital. However, RI has not produced copy of the said

document in which history is mentioned as one to one and half year from Sainath

Multispecialty Hospital.

AWARD Taking in to account the facts and circumstances of the case and submission made by both the parties, the Respondent Insurer is directed to settle the claim of Sainath Multispecialty Hospital for eligible amount as per policy terms and conditions in full and final settlement of the complaint. Hence the complaint is allowed.



PUNE



(UNDER RULE NO: 16( 1 ) /17 of THE INSURANCE OMBUDSMAN RULES, 2017)


Case of Smt. Sunita Bhanudas Bhoge v/s Life Insurance Corporation of India (Pune)



1. Name & Address of the Complainant:

Mrs.Sunita Bhanudas Bhoge Pune

2. Policy No & Type of Policy 959180557 LIC’s Jeevan Rakshak

3. Date of Risk Commencement & FUP 24.09.2014

4 Term/PPT / Premium / SA 827-10 1511.00 Mly UNDER SSS 200000

5. Dt.of Death & Duration of policy 04.12.2016 02Y/03M/10DAYS

6. Name of the Insured & Policy holder Mr. Bhanudas Ghanshyam Bhoge

7. Nature of complaint: Death Claim not paid

8. Relief sought: Death Claim of Rs.200000/-

9. Complaint how disposed: Claim Paid by RI

10. Date of Award: 15.10.2020

The complainant’s late husband Shri Bhanudas Bhoge was insured for Rs.2 lac with the RI vide

policy no.959180557. He expired on 04.12.2016. The Complainant (being the nominee) had

approached the RI for settlement of the death claim. There was 1 gap for due 11/14 as the

premium was not deducted from DLA’s salary. The claim was rejected by RI treating the policy

as lapsed.

An on line hearing was conducted on 05.10.2020 through video conferencing which was

attended by the complainant and Ms. Jayashree Deosthali representative of RI. The RI informed

that they are reconsidering the case and are willing to settle the claim.

On 13.10.2020 they have informed by e mail that the said claim is paid on Ex Gratia basis. Gross

claim amount 200000/- deduction of premium to complete anniversary and gap premium

15451/- Net paid 184549/- Payment is made on 09.10.2020 through NEFT.

Complaint is closed as the grievance raised with the Office of Insurance Ombudsman is

resolved.

Dated at PUNE, on this 15th day of October, 2020

VINAY SAH

INSURANCE OMBUDSMAN

PUNE





Case of Ms. Prachi Dharamdasani v/s Life Insurance Corporation of India



1. Name & Address of the Complainant Ms. Prachi Dharamdasani, Pune

2. Policy No. & Type of Policy 959681138, Endowment

3. Date of Com. Risk & FUP 19.08.2015, FUP as on DOD 09.2017 (As per Status rep)

4. Term/PPT & Premium Amount 16/09, Rs.2476/- Monthly-ECS

5. Date of Death Date of Risk Duration Cause of Death

26.07.2017 19.08.2015 01 y 11 m 07d Early Claim SBP with septicaemia with multiorgan failure


Mr. Vishal Jairam Dharamdasani Mr. Vishal Jairam Dharamdasani


8. Nature of complaint Death benefits regretted


10 Date of Repudiation 15.03.2018

11 Date of rejection by GRO(ZO DRC) 02.02.2019

12 Date of receipt of the Complaint 20.02.2019

13 Rule of I O under which the Complaint was registered

13 (1) (b)

14 Date of hearing & Place 05.10.2020, online (through video conferencing)


e) For the Complainant Self

f) For the Insurer Ms. Jayashree Deosthali




The complaint stemmed up due to the repudiation of the death claim by the Respondent

Insurer (RI) on the grounds of ‘Suppression of Material Facts’. Though the Complainant

represented her case to the Grievance Redressal Officer (G.R.O.) of the RI, it ‘UPHELD’ the

repudiation decision. Aggrieved by the repudiation decision of the RI, the Complainant

approached this Forum for consideration of the claim.


The Complainant vide her letter dated 20.02.2019 stated that her husband i.e. Deceased

Life Assured (D.L.A.) availed the said policy from the RI for a sum assured of Rs.3.30

Lakhs.

He expired on 26.07.2017 and when she being the appointee under the said policy,

preferred the death claim with the RI. However, RI rejected the death claim.

However, the RI settled the death claim on another two policies held by the D.L.A.

Hence, she has approached this Forum for settlement of death claim under the said

policy.


The RI, vide their SCN dated 19.03.2019 admitted to the issuance of the said policy,

based on the declarations made by the D.L.A. at the time of availing the policy.

The Complainant informed the RI about the death of the life assured due to ‘SBP with

septicemia with multiorgan failure’ and claimed the death claim on the policy moneys.

The RI investigated the death claim, and from the Hospital records of Jehangir

Hospital,Pune (ICU History Sheet Dated 21.07.2017) it is clear that the D.L.A. had a

history of IHD + Angioplasty around 12 years ago. The RI produced relevant records

pertaining to the D.L.A.

The D.L.A. had not disclosed the vital material information of his health and this

information was very important and had a bearing on the mortality risk of the life

assured. Had this vital information been declared by the D.L.A. the RI would not have

issued the said policy to the life assured. As the D.L.A. deliberately suppressed the

material fact relating to his health and previous ailment and therefore the RI denied the

death claim.

The RI further averred that the three policies i.e 993887475, 993887476, 959681138,

commenced on 03.02.2015,03.02.2015,17.08.2015, respectively and the amended

provisions of Sec 45 as per Insurance Laws Amendment Act 2015 would apply As per

the amended provisions, Zonal office, CDRC of RI had admitted the death claim under

policy nos 993887475, 993887476 and upheld the decision of repudiation of death claim

under policy no 959681138.


21) The following documents were placed for perusal: - 1. Complaint, copy of policy document and correspondence. 2. Consent form in Annexure VIA. 3. SCN from the Respondent Insurer and a copy of proposal form etc. 22) Observations & Conclusion:-

A hearing was conducted on 05.10.2020 through video conferencing. During hearing the complainant and the representative of RI reiterated their earlier submissions. The Forum after observing the records placed before it and after deliberations with the complainant and representative of RI, has observed as follows:-

The D.L.A. availed the said policy on 19.08.2015 for a sum assured of Rs.3.30 Lakhs with a premium of Rs. 2,476/- monthly. The D.L.A. had paid all the premiums under the said policy and the policy is in full force as on the date of death. As the said policy commenced after 26.12.2014 i.e. after the amended Sec 45 came into force, the Forum opines that amended provisions of Sec 45 is applicable in this case.

From the records placed before the Forum, it is seen that the D.L.A. had a history of IHD and he underwent angioplasty around 12 years ago as per the Hospital records of Jahangir Hospital (ICU History Sheet Dated 21.07.2017). The primary cause of death was SBP with Septicaemia with multi organ failure while secondary cause was Decompensated Liver cirrhosis’s in a K/Co HTN/DM and IHD. RI has submitted the above evidence to forum which clearly shows that DLA was suffering from IHD and underwent Angioplasty 12 years back and same was not disclosed in the proposal form dated 13.08.2015.

Hence the claim was repudiated by RI on grounds of fraud and decision informed to claimant vide letter dated 15.03.2018.

The repudiation of policy no. 959681138 was upheld by ZO DRC, while the claim of other 2 policies i.e.993887475 and 993887476 were admitted on ex-gratia basis and informed to complainant vide letter dated 02.02.2019.

The Forum notes that all these health complications and treatment being taken existed prior to the commencement of the policy and it was the duty of the D.L.A. to disclose the same. Had this pre-proposal illness been disclosed, the RI would have dealt with the proposal in a different way or not issued the policy at all. Hence RI is justified in calling the said policy in question. In view of the fact, the suppression of material facts is established.

The repudiation letter dated 15.03.2018 of RI clearly mentions that the suppression of material facts was clearly done with intent to deceive the Corporation.

AWARD Taking into account, the facts & circumstances of the case and the submissions made by both the parties during the course of online hearing, forum is of the opinion that RI in repudiating the claim under policy no. 959681138 has acted rightly as per terms and conditions of the Insurance contract and intervention of the Forum is not required. Hence the complaint is dismissed.

Dated at Pune,19.10.2020


PUNE




CASE OF Mrs.Sangita R Dodake V/S LIC of India.




Mrs. Sangita Satish Dodake,/Shivkrupa Sah Patpedhi Kasba Peth (Asignee), Pune


995729369 990396064 Jeevan Labh New Endowment

3 Date of Commencement 15.07.2016 24.08.2015

4 PPT Premium SA 25/16 16/16 S.A 200000(each) Rs. 867 mly Rs.1132 mly

5 Date of Death /FUP Duration of policy

11/08/2017 08/2017(both) 01 Yr. 26 Days 1 Yr 11 months 17 Days

6 Name of Insured Name of Policy holder

Mr. Satish R Dodake Mr. Satish R Dodake


8 Nature of Complainant Repudiation of Death claim

9 Relief sought Release of death claim payment

10 Date of Complaint to GRO Date of final refusal by RI

29.03.2018 14.09.2018

11 Reason for Rejection Suppression of material facts

12 Date of receipt of Complaint to OIO 17.10.2018


13(1)(b)

14 Date of hearing/Place Online hearing on 15.10.2020


A)For the Complainant Mr. Vikas Chavan Shivkrupa Sah. Pathpedi

B)For the Insurer Ms.Neha Godbole

16 Complaint how disposed Dismissed



The husband of the complainant, Shri Satish R Dodake (herein after referred as DLA i.e.

Deceased Life Assured) was insured under 2 policies, 995729369- Jeevan Labh and 990396064-

LIC New Endowment Insurance plan of the Respondent Insurer for a total Sum Assured of

Rs.400000/- since 15.07.2016 and 24.08.2015 respectively. He expired on 11.08.2017. The

cause of death was liver cirrhosis. The policies were assigned to Shivkrupa Sahkari Pathpedi

against a loan of Rs 5 lakhs advanced to DLA.The repudiation letter is also sent to the

Pathpedhi(assignee). The complainant (being the nominee before the assignment) had

approached the Respondent for settlement of the death claim. As per the Respondent, due to

non disclosure of medical history at proposal state, death claim was rejected. Late Mr. Satish R

Dodake was known case of liver cirrhosis, as per discharge summary received from Poona

Hospital and Research centre dated 26.05.2011 which is attached with the SCN by RI,.

Therefore the claim was rejected by the RI. Dissatisfied with the decision of the RI, the

Complainant has approached the Forum for relief. The relief sought is for the payment of death

claim in both policies.


The complainant reiterated that she had approached the insurer regarding why the

claim of her late husband’s policies was rejected but no attention was given to my

appeal to reconsider the claim

The proposal form was filled out by the insurance representative and the DLA had just

signed the form.

The DLA was not an alcoholic and the information was not suppressed deliberately.

She has two young children and no source of income. Shivkrupa Sahkari Pathpedi from

where DLA has taken loan has asked the complainant to demolish the house for loan

repayment. She has asked to favorably consider her case on humanitarian grounds.


The DLA was covered under LIC New endowment plan and Jeevan-Labh policy for sum

assured of Rs.200000/- (each) since 15.07.2016 and 24.08.2015.

He expired on 11.08.2017 and the cause of death was liver cirrhosis.

As it was an early claim, the investigation was initiated by them, RI found that Late Shri

Satish R Dodake was known case of liver cirrhosis and he has also undergone treatment

for Liver Cirrhosis, at Poona hospital in 2011and also clear from pathological reports of

15.03.2013 mentioning conclusion as LPD (cirrhosis)

On the basis of the investigation conducted, it was noted that the above mentioned

material information had been actively concealed while proposing for Insurance with an

intention to deceive the Corporation. If the said information had been disclosed at the

proposal stage, the policy would not have been issued.

The RI prayed before the Forum that the request made by the Complainant be rejected

and the complaint be dismissed.



registered.





Forms.


During the online hearing held on 15.10.2020 through video-conferencing, both the parties

reiterated their earlier submissions. The forum has the following observations to make:-

On page no.4 in Question no.11 of personal statement in the proposal form, the DLA

had answered ‘NO’ to all the questions about health although he was aware of his

illness and treatment being taken, but which he did not mention.

The RI has submitted documentary evidence from Poona Hospital and Research

centre,Pune,where it is clearly mentioned that the DLA was diagnosed and had

undergone treatment for liver cirrhosis,oesophageal varices and portal hypertension in

2011 which is prior to the date of proposals of both the policies.

RI has also submitted copies of medical certificates from Vasant clinic, Pune, dated

11.10.2013 and Sahayadri Hospital dated 03.08.2015 and 17.0.82015 which the DLA has

submitted to his employer when applying for sick leave where the reason is cited as CLD

and both are prior to the date of proposals. As per the amended section 45 of the

Insurance Act, 1938,a policy of life insurance may be called in question at anytime

within three years from the date of issuance of the policy or the date of commencement

of risk or the date of revival of the policy or the date of the rider to the policy,

whichever is later, on the grounds of fraud, provided that the insurer shall have to

communicate in writing to the insured or the legal representatives or nominees or

assignees of the insured the ground and materials on which such decision is based.

The RI has averred that the cause of death is clearly related with the undisclosed

ailment and it is clearly mentioned in the repudiation letter dated 27/02/2018 that

suppression of material facts was done with an intent to deceive the Corporation.

It is a fundamental principle of insurance law that utmost good faith must be observed

by the contracting parties.

The assured knew that he is suffering from liver cirrhosis with oesophageal varices and

portal hypertension and hence he was bound to disclose the fact at the time of proposal

as per the Doctrine of utmost good faith. The said illness if disclosed the proposals

would have been underwritten differently and affected the granting of risk under the 2

policies.

Forum finds no substance in the complaint.

AWARD Taking into account the facts and circumstances of the case and submissions made by both the parties during the course of hearing, the forum observes that the RI, in repudiating the death claim under both the policies has acted rightly as per the terms and conditions of the policy and does not require intervention of the Forum. As such the complaint is dismissed.

Dated at Pune, on this 19th day of October 2020.

VINAY SAH

INSURANCE OMBUDSMAN

PUNE



UNDER SECTION 16(1)/17 OF THE INSURANCE OMBUDSMAN RULES-2017 OMBUDSMAN–VINAY SAH

CASE OF Smt.Shashikala G DupareV/S L.I.C.OF INDIA

COMPLAINT NO: PUNE-L-029-1920-006



Smt. Shashikala G. Dupare. Nagpur


973796358 LICs Jeevan Saral with profits

3 Date of proposal 29.10.2011

Date of Commencement FUP DOD DURATION

28.10.2011 10/2012 30.09.2012 11 months 2 days

4 PPT Premium Mode SA

165/16/16 408.00 MLY SSS Rs.100000

5 Insurance Intermediary LIC Agent Rahul Chanduji Bisane


GajananSampatraoDupare 52 GajananSampatraoDupare


8 Nature of Complainant Death claim not paid


10 Date of repudiation Date of Representation to GRO Date of refusal by RI

06.03.2014 08.01.2015 5.03.2015

11 Reason for Rejection Suppression of material facts


28..03.2019


13(1)(b)

14 Date of hearing/Place Online , 15.10.2020 (through video-conferencing)


A)For the Complainant Could not be traced.and contacted on date of hearing

B)For the Insurer Mr.B.Z.Urkude

16 Complaint how disposed Dismissed.



Smt.Shashikal G.Dupare wife (Nominee) of deceased policy holder Shri Gajanan C.Dupare

holder of LIC’S Jeevan Saral Policy bearing no.973796358 has preferred a complaint against LIC

for non-settlement of Death claim. The insured policy holder died on 30.09.2012 due to

fever/Malaria/Chills ARF CAFL at the age of 53.She had preferred death claim under policy.

However, the same was regretted.


Deceased Shri Gajanan C.Dupare had taken Insurance policy bearing no 973796358with a

premium of Rs.408.00 per month under SSS mode for SA of Rs.100000 on 28.10.2011 just 11

months 2 days before his death. He paid regular premiums. He died on 30.09.2012 in hospital

due to Malaria/fever/Chills PCF C CRA. Being the nominee under the policy, complainant

preferred insurance death claim before LIC. The claim was rejected by LIC and on appeal to

Mumbai Zonal office, the decision of repudiation was upheld. After the untimely death of her

husband who was working as a laborer, she has no earning member in her family. She is

illiterate and does not understand English. She claims that the form was filled by agent and

though her husband was partially paralytic in right hand which was visible, it was not

mentioned in the proposal form and also did not reflect in Medical form. This was done

deliberately by agent for his gain. Being aggrieved she has approached the Office of Insurance

Ombudsman.


RI has admitted to Issuance of the Policy as per terms and conditions of policy bond. The LA

died on 30.09.2012 after a period of 11months and 2 days from the commencement of risk

under said policy at Government Medical College Hospital Nagpur. Cause of death as per claim

form B Primary ARF with PCF C CRA in a K/C/O RHD C AVR done. Being very early claim the

claim was investigated keeping in view Sec 45 of Insurance Act1938. It was revealed that

deceased LA was suffering from RHD and heart problem and AVR (Aortic Valve Replacement) in

2002 which was prior to date of commencement of this policy ie.28.10.2011. He failed to

disclose this in his Personal Statement regarding health at the time of filling the proposal form

Question No 11(a) to 11(j).The decision to repudiate the claim was taken on the strength of

(Page 53)Discharge card of Super Specialty Hospital Nagpur ,DOA 19.12.2001,DOD

11.1.2002/AVR done on 20.12.2001,(Page 44)Record of Govt. Med. College Nagpur K/C/O RHD

C MVR done AVR,(Page 41) Medical Pathology Lab Dt.25.09.2012, Patient is A/R/C/O RHD C

AVR done (2002) and (Page 32) Medical paper of Phes K/C/O RHD AVR done (10Years back) at

SSH Nagpur. ZO CDRC up held the decision to repudiate the claim taken by Nagpur Division. The

RI has claimed that they have rightly repudiated the claim and have requested the forum to

dismiss the case as nondisclosure of this material facts was deliberate on the part of Life

Assured and had a direct bearing on granting risk.


The complaint falls within the scope of Insurance Ombudsman Rules,2017 and so it was

registered.




3)SCN along with consent from the Respondent Insurer and copy of proposal

form.


During the online hearing held on 15.10.2020, through video-conferencing both the parties

reiterated their earlier submissions. The forum has the following observations to make:-

The deceased LA was 52 years of age at the time of taking the said policies in question.

This was his first insurance. His right hand was paralyzed according to DLA’s wife but

same is not reflected in proposal form dated 29.10.2011.

The deceased LA died within 11 months and 2 days after taking the policy under

contention on 30.9.2012

RI has submitted evidence in the form of treatment papers and Discharge card on

record to prove that Life Assured was hospitalized from 19.12.2001 to 11.01.2002 in

Medical P.G Institute Super Speciality Hospital Nagpur as k/co RHD and operated for

AVR which was prior to the date of proposal 29.10.2011 From the Discharge card and

medical treatment documents it is clear that DLA has not disclosed his illness and

treatment taken prior to taking this policy in question which he was bound to disclose

and thus the principle of Uberrimae fidei has been breached.

RI repudiated the claim on the grounds of deliberate misstatement and withholding

information regarding his health and the repudiation decision was informed to claimant

vide letter dated 05.04.2014.ZO DRC also upheld the decision of repudiation of the

claim.

The delay in taking policies at advanced stage after diagnosis of decease in 2001/2002

also indicates the mala fide intention of the deceased LA.

Forum does not find any substance in the complaint.

AWARD Taking into account the facts and circumstances of the case and submissions made by both the parties during the course of hearing, forum is of the opinion that RI in repudiating the death claim under policy no.973796358 has acted rightly as per terms and conditions of the Insurance contract and intervention of the Forum is not required. Hence the complaint is dismissed.

Dated at Pune on this 19thday of October,2020

VINAY SAH

INSURANCE OMBUDSMAN

PUNE



(UNDER RULE NO: 16(1)/17 of INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – VINAY SAH

CASE OF SHEELA SANDIP BIRHADE v/s LIFE INSURANCE CORP.OF INDIA


Award No: IO/PUN/A/LI/ /2020 - 21


Smt. Sheela Sandip Birhade Jalgaon

2. Policy No / plan-term / SA Name of Policy:

961966673 /815-20 /1,00,000 New Jeevan Anand

3. Date of Commencement: 28.06.2014

4. Premium / Mode / FUP 509 / SSS / 06/2017

5. Date of Death: 28.07.2017

6. Duration of Policy: 3 years 1 month

7. Life Insured: Name of the Policyholder:

Sandip Prakash Birhade

Sandip Prakash Birhade

8. Name of the Insurer: LIC of India, Nashik DO

9. Date of Repudiation: 21.12.2017

10. Reason for repudiation:

Policy in lapsed condition

11. Date of receipt of the Complaint: 26.04.2018

12. Nature of complaint: Repudiation of Death Claim

13. Amount of Claim: ₹100000/-

14. Rule of IOR under which the Complaint was registered:

13(1) (b)

15. Date of hearing/Place: 15.10.2020 online video conferencing


g) For the Complainant: Herself

h) For the insurer: Smt. Lata Shahane, Shri. Nitin Malvi

17. Complaint how disposed: Dismissed

18. Date of Award: 30.10.2020


The husband of the Complainant, Shri. Sandip Prakash Birhade (here in after referred as DLA i.e.

Deceased Life Assured) was insured with the Respondent under plan 815 (DOC: 28.06.14) for

the Sum Assured of Rs. 1,00,000/-. The insured died on 28.07.17 due to acute myocardial

Infarction. The Complainant (being the nominee) had approached the Respondent for the

settlement of death claim. As per the Respondent, the duration of the policy is three years and

policy was not in force as two premiums are not paid. The policy was issued under Salary

savings scheme and had two gaps of 04/2016 and 04/2017 and SSS exgratia is not applicable to

the plan. Therefore, the claim was rejected by the Respondent as the policy was in lapsed

condition. Dissatisfied with the decision of the Respondent, the Complainant has approached

the Forum seeking the intervention of the Hon. Ombudsman in resolving the dispute. The relief

sought is for the sum assured under the policy.


The complainant contends that her husband died of heart attack. LIC has rejected the

death claim because of 2 pending premiums. Her husband had no knowledge of gaps

(in premium) neither was he informed about it. She has no other income source, has a

5 ½ yr. old daughter. She requests to consider her case sympathetically so that the

purpose of taking the policy is served.

21) Contentions of the Respondent:

There were two gaps of 04/2016 and 04/2017 in the SSS premiums.

SSS exgratia is not applicable for this plan.

Thus due to shifting of the gaps the policy becomes lapse and hence the claim is not

payable under the policy.

22) Observations & Conclusion:

Hearing was conducted online on 15.10.2020. during the hearing both the parties

reiterated their earlier submission. Forum observes that:

The DLA was working as Sweeper in Amalner Nagarpalika. He died at the age of 33 due

to heart attack on 28.07.2017

All the premiums till 05/2017 were received except two intermittent premiums 04/2016

and 04/2017. Then again, premium due 06/2017 not received. As the DLA died on

28.07.2017, premium of 07/2017 had also fallen due.

The concerned PA (paying authority) was habitually remitting premiums in a delayed

manner. Time lag for remittance of premium was found to be 2 to 3 months.

Hence, Forum asked RI whether the premium for 06 and 07/2017 were received

subsequently as also to ascertain the reason for not remitting premium for 04/2016 &

04/2017 from the employer.

RI vide their mail dt. 29.10.2020 have informed that as per letter dt.28.10.2020 from

DLA’s employer, salary for 04/2016, 04/2017, 06/2017 & 07/2017 was not drawn as he

had remained absent during these months.

As per clause 22 for SSS policies, it is the responsibility of the policyholder to pay the

premium and keep the policy in-force in case the premium is not remitted through

salary for any reason.

In the instant case, as the policy has just completed only 3 years and total no. of unpaid

premiums are four, no any concession or ex gratia clause is applicable. Hence, the status

is ‘lapsed’ as on date of death.

As such, Forum has no alternative but to uphold the decision of RI to reject the claim.

Dated at Pune, this 30 day of October 2020

VINAY SAH

INSURANCE OMBUDSMAN

PUNE

AWARD

Taking into account the facts & circumstances of the case and the submissions made by both

the parties during the course of hearing, the complaint does not sustain. Hence, dismissed.




CASE OF Mrs.Sushila B Desai V/S LIC of India.




Mrs. Sushila B Desai Dodamarg, Sindhudurg


948534298 948534299 948534300 Money Back/ Endowment / New Jeevan Anand

3 Date of Commencement FUP Mode DOD DURETION

28.07.2015 28.07.2015 28.07.2015 11/2017 Mly under SSS / 13.11.2017 2 Years 3 Months 15 Days (All Policies)

4 PPT Premium SA 820/20/15 814/15/15 815/15/15 777 1268 822 100000 200000 100000

5 Insurance Intermediary LIC agent


Mr. Baliram Amrit Desai (Deceased) 50 Mr. Baliram Amrit Desai


8 Nature of Complainant Death claim not paid


10 Date of Representation to GRO Date of refusal by RI

13.06.2018/25.08.2018 12.09.2018

11 Reason for Rejection Policy in Lapsed condition. 1 SSS gap, SSS ex gratia concession not allowed


22.10.2018


13(1)(b)

14 Date of hearing/Place Online 6.10.2020 (through video conferencing)


A)For the Complainant Swapnil Desai

B)For the Insurer Mr. Nigudkar

16 Complaint how disposed Allowed.



The complainant is the wife and nominee of deceased life assured. Deceased LA had

purchased 3 insurance policies, on his life, from LIC of India. He had no other policies in his

name. The premium was deducted under SSS mode from salary account directly. He died on

13.11.2017 due to accident .The complainant submitted death claim. Her claim was rejected by

the RI on the grounds that the policy was in lapsed condition due to nonpayment of monthly

premium due 9.2016 resulting in a gap and nothing was payable. Her appeals were turned

down and as such she has approached the Forum for relief.


The deceased LA was insured under 3 Insurance Policies bearing no’s 948534298 /

948534299 / 948534300 for total SA of 400000.The premium for all the policies was deducted

from his salary every month. Last premium deducted was in the month of 10.2017 and FUP was

11.2017. He died on 13.11.2017. His death claim lodged with LIC was rejected with remark

nothing payable under policy as policies are in lapsed condition due to nonpayment of monthly

due premium 9.2016. Her appeals for consideration of claim were turned down. In view of the

said facts Complainant has approached for relief by way of death claim settlement.


The respondent insurer has admitted the details of policies under litigation. As per clause

22, signed by life assured, taken along with proposal, it is mentioned that the policy stands

lapsed if due premium is not received by corporation within 15 days from due date. According

to them all the premiums except 09/2016, up to 10/2017 from commencement of policy i.e.

28.07.15 were received. In view of the gap of 09/2016 policy is in lapsed condition and SSS ex

gratia clause is not applicable for this plan as policies were taken after 01.01.2014.The actual

FUP of 11/2017 was shifted back to 10/2017 in view of 1 gap. The policy was in lapsed condition

on the date of death and such the claim cannot be entertained. The complaint may be

dismissed.



registered.





form.


During the online hearing held on 6.10.2020 through video conferencing, both the parties

reiterated their earlier submissions.

The Forum has the following observations to make:-.

All the 3 Policies were issued under salary saving scheme of the Corporation.

The death claim under policy has been summarily rejected by RI only because one

monthly premium due 09/2016 was not recovered by employer from DLA’s salary

leading to 1 gap premium in the 3 policies. The policies commenced w.e.f. 28.07.2015

and first two monthly premiums due 7/2015 and 08/2015 were paid in cash at the

proposal stage.

There after all premiums were regularly deduced from deceased LA”s salary and

remitted to LIC except for the due 9/2016.

As per latest internal circular issued by Central office of LIC under reference

CO/CRM/1184/23 dated16.12.2019 ,a maximum of 3 gaps have been allowed for

reconsideration as per merits and decide suitably in this regard.

AWARD Taking into account the facts and circumstances of the case and submissions made by both the parties during the course of hearing, the forum directs the Respondent Insurer to settle only basic death claim under all the 3 policies immediately, as per fresh guidelines of RI’s Central office in this regard. The complaint is Allowed.

Compliance of the Award:-

The attention of the Complainant and the Insurer is here by invited to the following provisions

of Insurance Ombudsman Rules 2017:

A) According to Rule 17(6) of Insurance Ombudsman Rules 2017, the Insurer shall comply with

the Award within 30days of the receipt of the Award and intimate the compliance of the same

to Ombudsman.

B) According to Rule 17(8) of Insurance Ombudsman Rules 2017, the Award of Insurance

Ombudsman shall be binding on the Insurers.

Dated at Pune on this 9th day of October 2020.

VINAY SAH

INSURANCE OMBUDSMAN

PUNE



(UNDER RULE NO: 16( 1 ) /17 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN –VINAY SAH

Case of Mrs. Varsha Sunil Kulkarni v/s Life Insurance Corporation of India



1. Name & Location Ms. Varsha Sunil Kulkarni, Pune

2. Policy No. 999161028 SP Endowment 999251947 –SP Endowment

3. Date of Risk & Date of Proposal 30.03.2015(30.03.2015) 07.01.2016(04.01.2016)

4. Term/PPT Premium Amount/SA

Term 10Y-Single Term 10Y-single Rs.371050-SA 5Lac. Rs.371650/SA 5Lac.

5. Date of Death Date of Risk Duration of policy Cause of Death

08.08.2017 08.08.2017 30.03.2015 07.01.2016 2Y-4M-8D 1Y-7M-7D Metastatic CA buccal mucosa (Form-B)

6. Name of the Insured: Shri SUNIL PRABHAKAR KULKARNI

Name of the Policyholder: Shri SUNIL PRABHAKAR KULKARNI

7. Name of the Insurer: Life Insurance Corporation of India

8. Nature of complaint: Repudiation of death benefit

9. Relief sought: Payment of death benefits under the policies

10. Date of Refusal by RI 16.01.2018 , 23.04.2018-ZOCDRC(GRO)


12. Rule of I O under which the Complaint was registered:

Rule No.13 ( 1 ) ( b )

13. Date of hearing/Place: 05.10.2020. online(through video conferencing)


i) For the Complainant: Self

j) For the insurer: Smt. Jyoti Kale

15. Complaint how disposed: Partially Allowed

16. Date of Award: 09.10.2020


The complainant, wife and the nominee of the deceased, and DLA had purchased the single

premium policies from RI through Bank assurance channel. The policies were canvassed against

educational loan for their daughter. The LA , Sunil Kulkarni,died within 3 years from the

commencement of the policies. The death claim was repudiated by RI due to non disclosure of

the material fact. Hence, the complaint.

18) Contentions of the Complainant:-

The life assured and complainant were in need of educational loan for their daughter in

year 2015. They approached to their banker- Corporation Bank for the same. The

dealing official from bank insisted on taking two Insurance policies from them (one each

from complainant and her husband-DLA) in March 2015 for sanctioning educational loan

and two more policies in January 2016.

The DLA had informed the official about the existing illness and treatment taken

thereof. Inspite of this the bank official insisted them for the policy and were

pressurized to sign the blank the proposal forms .The complainant has produced

partially filled proposal form duly signed by DLA. The contention is also that the said

proposal form might have been filled subsequently without mentioning the history of

illness and present treatment.

The proposal forms were filled by the marketing official of RI, in his handwriting .The

complainant has enclosed the copy of the DLA’s diary to prove that the DLA had not

filled the same.

Therefore putting blame on LA for non-disclosure is not correct and fair as proposer has

signed the blank proposal form under pressure of loan approval.

As the complainant has the responsibility of her in laws and repayment of the

educational loan .she approached to the forum for relief.


The RI has submitted SCN along with the documents like claim forms, discharge

summary from Deenanath Mangeshkar Hospital, IR, Repudiation letter and the

evidences collected to support the repudiation etc.

The claim was repudiated due to non disclosure of the illness and the treatment taken

thereof, in the proposal form. The DLA was k/c/o Ca Rt Alveolus and was undergoing the

definitive radiotherapy treatment. The RI has collected the supportive documents dt

06.03.2010 from Deenanath Mangeshkar Hospital, Pune and also discharge summary

dtd. 09.04.2010, 24.04.2010.

The history of the illness and the treatment goes prior to the date of proposal.

The RI’s contention is that LA had taken treatment and was aware of treatment, this

proves a non-disclosure. Hence the claim is repudiated.

The decision of repudiation is upheld by the ZO-CDRC also.

It is mentioned in the Repudiation letter that “This suppression of material facts, which

have had a bearing on the granting of risk, was clearly done with intent to deceive the

Corporation. Hence it has been decided to repudiate all the liabilities under the

afforested policies and all the money received by Corporation under the afforested

policies stands forfeited in terms of policy terms and conditions”.

20) Reason for Registration of complaint:-

The complaint falls within the scope of Insurance Ombudsman Rules, 2017 section 13 (1) (b)

and so, it was registered.

21) The following documents were placed for perusal:-

1. Complaint, copy of policy documents, proposals and correspondence.

2. Consent in Form No. Annexure VIA & VIIA.

3. Various documents of treatment as an evidence and copy of repudiation letter etc.

22) Observations & Conclusion:-

A hearing was conducted on 05.10.2020 through video conferencing .During hearing the

complainant and the representative of RI reiterated their earlier submissions. The Forum has

following observations to make:-

The policies were sourced through bank assurance channel against the requirement

of educational loan.

Policy No.999161028 completed through same channel (Corporation Bank) was

neither disclosed in proposal for Policy No.999251947 taken subsequent to this policy,

nor was verified by RI at the time of accepting the risk.

Similarly Single premium policies with same duration were also sold to complainant,

who was witnesse to the loan process.

Documents available regarding treatment prior to signing proposals i.e. 30.03.2015 & 04.01.2016.

A).Treatment papers, discharge summary from Deenanath Mangeshkar Hospital,Pune for radiation therapy done in 2010 with diagnosis of k/co CA Rt alveolus, ulcer over Right max alveolus and invasive moderately differentiated squamous carcinoma & similarly diagnosis for discharge summary dated 22/10/2015. B).Same details are available in history of Death Summary (Sr. No.39) dated 08.08.2017 by Maharashtra Medical Foundation-Joshi Hospital, Pune & Discharge summary (Sr. No.47) of Phadnis Clinic, Pune. dated 13.03.2017.

The date of 2nd proposal is 04.01.2016 and history of PET scan on 06.01.2016 and tumor surgery on 14.01.2016 and risk commencement date is 07.01.2016.

The policies opted by LA and complainant are of single premium having death risk to

insurer is very less which can be observed as follows:-

Policy

No.

Name SUM ASSURED

PREMIUM NET RISK Total Net

Risk for DLA

999161028 SUNIL-LA 500000 371050 128950 257300

999251947 500000 371650 128350

999251948 VARSHA-

COMP.

450000 330817 119483

999161025 350000 257302 092698

Looking at the amount invested as single premium and amount of risk covered,it does not

seem logical for DLA to go for risk cover of Rs 1000000/-(Net risk Rs 257300/-).- by investing

Rs.742700/-. With a fraudulent intension, the LA would have gone for a much higher risk cover

with same premium and under other modes of premium payment, instead of single premium

and proposed further policies on his own life instead of two single premium policies on the life

of his wife.

The forum finds some substance in the complaint.

AWARD Taking into account the facts and circumstances of the case and submissions made by both the parties, the Respondent Insurer is directed to refund the premiums received under the policies bearing nos.999161028 and 999251947 without any further delay in full and final settlement of the complaint. Hence the complaint is partially allowed.

23. The Compliance of Award:- The attention of the complainant and the insurer is hereby invited to the following provisions of Insurance Ombudsman Rules 2017.

a) According to Rule 17(6) of Insurance Ombudsman Rules 2017, the insurer shall comply with the Award within 30 days of the receipt of the Award and intimate the compliance of the same to the Ombudsman. c) According to Rule 17(8) of Insurance Ombudsman Rules 2017, the Award of Insurance Ombudsman shall be binding on the Insurers. Dated at Pune, 09.10.2020


PUNE





Case of Mr. Vishal Nimbalkar v/s Bharti AXA Life Insurance Co. Ltd.



1. Name and Location of complainant Mr.Vishal Nimbalkar Akola

2. Policy No. & Type of Policy 501-3808745 30/12/2015 Dt of proposal 11/12/2015

10/5, / Rs.25908/-, Yly/103730/-

3. Dt of Issue of Policy & Date of Proposal

4. Term/PPT,/ Premium & Mode /S.A

6. Name of the Policyholder Name of the Insured

Late Vasantrao Sitaram Nimbalkar Late Vasantrao Sitaram Nimbalkar

7 Date of Death Duration of the policy

23.12.2017 1Y-11M-25D

7. Name of the Insurer Name of the Agent

Bharti AXA Life Insurance Co. Ltd. Nirav Bhojak

8. Nature of complaint Death claim repudiation

9. Relief sought Death claim amount

10. Date of rejection by Insurer 22.02.2018



13 (1) (d)

13. Date of hearing & Place 06.10.2020, online(through video-conferencing)


k) For the Complainant Vishal Nimbalkar

l) For the Insurer Snehal Sawant


16. Date of Award 12.10.2020


The Deceased Life Assured (DLA) had insured with RI under the policy bearing number 501-

3808745 in 2015. The LA died within 2 years from date of risk. The RI has repudiated the claim

for non-disclosure of material information, hence the complaint.


The deceased had surrendered the earlier policy and purchased the new policy through representative of RI in Dec 2015 under annual mode.

The 1st renewal premium was also paid by the DLA.

The LA died on 23.12.2017 due to Massive Heart Attack. The complainant, being nominee under the policy has lodged the death claim with RI but the same was rejected due to non disclosure of past illness.

The contention of the complainant is that while opting new policy the LA had disclosed the medical history of CABG, HTN and DM to concern agent but the same was not incorporated in proposal form.

Hence the complainant has approached the forum for the relief.


The RI has stated that the contents of the application and the policy features were read

over and explained to the LA before he voluntarily filled up and signed the proposal

form and then only the policy was issued.

It is pertinent to note that right from proposal stage it was always made abundantly

clear to LA that truthful answers to questions in the proposal form are of immense

importance for accepting life insurance proposal of life LA and obligation of disclosing

true fact continue even subsequent to signing of proposal form before acceptance of

risk by RI.

The policy was issued on 30.12.2015 and delivered on 14.01.2016.

The RI received the death intimation under the policy along with the claim form and

other documents. The LA died on 23.12.2017 due to Accelerated HTN, post CABGE

massive intracelebral respiratory arrest. The death occurred within 2 years and being

an early claim the investigation has been carried out.

It was revealed that the LA had gone through CVA in 2012 and had CABG done in 2013.

Also he was admitted at Kamalnayan Bajaj Hospital from 21.11.2013 and was a known

case of HTN, DM.

As the said illness were prior to signing the proposal, the claim was repudiated for non

disclosure of the same in the proposal form.

The complaint may be dismissed.

20) Reason for registration of complaint: - The complaint falls within the scope of Insurance Ombudsman Rules, 2017 and so, it was registered. 21) The following documents were placed for perusal: - 1. Complaint, copy of policy document and correspondence. 2. Consent form in Annexure VIA.

22) Observations & Conclusion:- A hearing was conducted on 06.10.2020 through video conferencing. During hearing

the complainant and the representative of RI reiterated their earlier submissions. The Forum

has following observations to make:-

The policy was sourced through the representative of RI.

According to the complainant DLA had no health issues at the time of filling and signing

the proposal form dated 11.12.2015

After receiving the death intimation by RI, being an early claim investigation was

carried out as per provisions of Section 45 of the Insurance Act 1938 and it was

revealed that the deceased was admitted in Kamalnayan Bajaj Hospital Aurangabad

from 21/11/2013 to 01/12/2013 for HTN with DM, TVD and CABG was done. The copy

of discharge card with date of admission 21.11.2013 and date of discharge 01.12.2013,

is submitted by the RI to the forum

The said history of illness was not disclosed while opting for the insurance which he

was bound to disclose, thereby violating the Principle of utmost good faith. Hence the

claim was repudiated by RI for suppression of material facts and claimant informed

vide letter dated 22.02.2018

If the aforesaid information was disclosed, it would have had a bearing on the

acceptance of risk and the RI would not have issued the mentioned policy at all.

The forum does not find any substance in the complaint.

AWARD

Taking into account the facts and circumstances of the case and submissions made by both

the parties and evidence placed on record during the course of online hearing, the forum is of

the opinion that the RI has acted rightly in repudiating the claim under policy no. 501-

3808745 as per terms and conditions of the policy and therefore intervention of the forum is

not required.

Hence the complaint is dismissed.



PUNE

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. AND UTTARAKHAND

UNDER INSURANCE OMBUDSMAN RULES 2017

OMBUDSMAN – SHRI C. S. PRASAD

CASE OF MANOJ KUMAR BHARDWAJ V/S BAJAJ ALLIANZ LIFE INSU. CO. LTD.

COMPLAINT REF: NO: NOI-L-006-2021-0098

:1. Name & Address of the Complainant Mr. Manoj Kumar Bhardwaj

B-65, New Colony Kasimpur Power House

Aligharh

M- 7500499285

2. Policy No:

Type of Policy

Duration of policy/Policy period

0347811278

LIFE

5/10


Name of the policyholder

Late Smt. Rekha Sharma

Late Smt. Rekha Sharma

4. Name of the insurer Bajaj Allianz Insurance Co. Ltd.

5. Date of Rejection 31-12-2019

6. Reason for rejection Non disclosure of pre existing disease



9. Amount of Claim


11. Amount of relief sought Death Claim payment


IOB rules

Yes

13. Date of hearing/place 5-10-2020/ NOIDA


a) For the Complainant Mr. Manoj Kumar Bhardwaj

b) For the insurer Ms. Swati Seth

15 Complaint how disposed Settlement

16 Date of Award/Order 09-10-2020

17 . Brief Facts of the case : The complainants ‘sister Mrs. Rekha Sharma purchased above mentioned policy from Bajaj Allianz Life Insurance Company on 4-07-2018. The life assured expired on 7-07-2019 due to sudden heart attack. The complainant had submitted the papers for payment of death claim. The insurer stated that the life assured was suffering from kidney disease and elevated blood Urea before purchasing the policy. The insurer rejected the claim due to non disclosure of pre existing disease by the assured. The complainant stated that assured was healthy at the time of purchasing the policy and approached the Ombudsman Office on 1-07-2020, for settlement of death claim of his sister.

18. Cause of the complaint:

Complainant’s argument : The complainant is the brother of the life assured Mrs. Rekha Sharma. Mrs. Rekha had purchased the policy in July 2018 for Sum assured Rs 5,00,000/- with annual premium of 50,000/- . She had paid two annual premiums. Her husband had already expired. She had purchased the policy for protection of her daughter and son aged 14 and 12 years respectively. She was healthy and had no disease at the time of purchasing of policy. On 7th July 2019, all of sudden she had some health issue, and was taken to Prithvi Raj Hospital Aligarh, and on way to the hospital she expired. The Hospital declared the death was due to Cardio Respiratory Failure. The complainant is an appointee of the minor children of the assured Mrs. Rekha. When the complainant applied for death claim of Mrs. Rekha, the insurance company rejected the claim by letter dated 31-12-2019, stating that Assured was suffering from kidney disease since 2017 and did not tell the facts at the time of purchasing the policy. The insurance company instead of giving the death claim against the policy transferred Rs 85,460/- in the complainant’s account. The complainant stated that as per his knowledge company had done medical examination of his sister before issuing the policy. But insurance company is denying from any medical examination at that time. He claims that amount should be paid.

Insurer’s argument : The insurer has stated that the policy was issued in July 2018 and life assured died in July 2019.The complainant had submitted the certificate of Prithvi Raj Hospital that assured was died due to cardio respiratory failure, but insurer has submitted the test reports dated 24-03-2017 of the life assured Mrs. Rekha, issued by Ashok Pathology & research Center Aligarh. On the basis of result of different investigations, there was elevated blood urea and abnormal CBC reports. Insurer stated that the assured was suffering from kidney disease. The test reports pertain to year 2017, assured did not disclose the fact at that the time of purchasing the policy. The life assured was well aware that she was suffering from kidney disease. Despite being specifically asked to disclose the aforesaid conditions in the proposal form, the assured deliberately and fraudulently supported these material facts . The insurer denied any medical examination at the time of selling of policy because as per rules, till age 40 for sum assured Rs. 6 lacs no medical examination was required. The insurer confirmed that due to non disclosure of the facts claim was rejected and also as per the rules of the company for ULIP policy the fund value was returned to the complainant. 20. Following documents were placed for perusal:

1. Complaint letter. 2. Copy of proposal forms and IDs 3. SCN 21. Observation and conclusion : Both the parties appeared for online hearing and reiterated their submissions. The complainant contended that his sister died after one year of purchase of policy by sudden heart attack. They were taking her to hospital, and on the way she died. Doctor declared the death was due to cardio respiratory failure. The claim papers were submitted to the insurance company. This was an early claim, so investigation was done and insurer declared that assured was suffering from kidney disease before purchasing the policy and repudiated the claim. In the support, insurer submitted few test reports in the name of Mrs. Rekha Sharma. The test reports were showing some deviations from the regular range of results. The tests were done on self request and no doctors consultation or treatment details were available. The insurer on the basis of these reports repudiated the death claim.

I have examined the documents exhibited as evidence and oral submissions made by both the

parties. The insurer has submitted three reports, which are without any doctor’s prescription

or consultation advice. These reports, pertaining to the year 2017, only show some deviation in

the blood, which cannot be taken to prove that the patient had kidney problems. More

importantly, these reports in the name of Mrs. Rekha is no proof that they pertain to the

assured of the policy. The insurer confirmed that their investigation officer could not provide

other related papers of the reports, and also conceded that the reports cannot be taken as a

proof that the assured had kidney disease before purchasing the policy. Hence, the insurer

offered to settle the claim in favour of the complainant.

RECOMMENDATION

Taking into account the facts and circumstances of the case and the submission made by both the parties during the course of hearing , the insurance company is directed to settle the claim in favour of the complainant, as agreed during hearing.

The complaint is disposed off accordingly.

22. The attention of the Complainant and the Insurer is hereby invited to the following provisions of the insurance Ombudsman Rules 2017: As per rule 16(3) of Insurance ombudsman rules 2017, the insurer shall comply with the terms of recommendation immediately but not later than fifteen days of the receipt of such recommendation , and inform the Ombudsman of its compliance

Place: Noida. C.S. PRASAD Dated: 09.10.2020 INSURANCE OMBUDSMAN (WESTERN U.P. & UTTARAKHAND)

PROCEEDINGS BEFORE



OMBUDSMAN – SH. C.S.PRASAD

CASE OF SMT. RADHA V/S LIFE INSURANCE CORPORATION OF INDIA


AWARD NO:

1. Name & Address of the Complainant Smt. Radha W/O Late Sh. Manish Kumar

H.No. 35, Village Tah, Post –

Mohaddinpur

Tehsil- Puwaya, Shahjahanpur,

Uttar Pradesh-242042

2. Policy No: 224671625

Type of Policy


Life Plan

16/16



Late Sh. Mahesh Kumar

Late Sh. Mahesh Kumar

4. Name of the insurer Life Insurance Corporation of India


6. Reason for repudiation

Non-Disclosure of Material facts of

Illness


8. Nature of complaint Repudiation of Death Claim

9. Amount of Claim Rs.1.50 Lakh


11. Amount of relief sought Rs.1.50 Lakh


IOB rules

13.1.d

13. Date of hearing/place 14.10.2020



b) For the insurer Sh. Anil Saxena and Pawan Raj Mittal

15 Complaint how disposed Award


17)Brief Facts of case ;- This complaint is filed by Smt. Radha against decision of LIC of India relating to repudiation of death claim under policy no. 224671625 issued on the life of her husband Late Sh. Mahesh Kumar.

18)Cause of Complaint:- Repudiation of Death Claim of Policy.

a)Complainants argument :- The complainant stated that that her husband had taken a policy from LIC of India on for sum assured of Rs.1.50 lakh under plan and term 814/16/16 with date of commencement 22.12.2017. Her husband died suddenly at home on 29.12.2017. The complainant had submitted all the relevant claim forms to the insurer. The insurer had repudiated payment of Death Claim on the ground of non disclosure of pre-existing disease.

Insurers’ argument:- :- The insurer stated that a policy was issued on the life of Sh. Mahesh Kumar on the basis of duly filled and signed proposal form on 22.12.2017. According a policy no. 224671625 was issued on under plan and term 814 -16-16 for sum assured of Rs.1.50 lakh. The insurer received intimation of death of the life assured on 29.12.2017 along with claim forms from the complainant. The complainant died with in 7 days of inception of policy which resulted in early death claim. During investigation it was found that the complainant had taken treatment on O.P.D. basis on 19.12.2017 from Dr. Sandeep Kumar of Dhanvantri Tomer Hospital, Bareilly. As per prescription of New Dev Medical Store, Puwaya, the DLA was suffering from B/L Extensive Pulmonary tuberculosis since 27.4.2017, which the DLA did not disclose at the time of filling proposal. The DLA had replied in negative to questions related to the health. Hence the death claim payment was repudiated on the ground of concealment of material facts of illness under the policy.

19) Reason for Registration of Complaint: Scope of the Insurance Ombudsman Rules 2017.

20) The following documents were placed for perusal. a) Complaint Letter b) Repudiation Letter c) Policy Document d) SCN

21) Observations and Conclusion:- On line hearing in the case was held on14.10.2020.Both parties appeared for on line hearing and reiterated their submissions. The complainant submitted that her husband died suddenly at home on 29.12.2017. The complainant had submitted all the relevant claim forms to the insurer. The insurer had repudiated payment of death claim on the ground of non disclosure of previous illness. The insurer submitted that the complainant died within 7 days of inception of policy. During investigation, it was found that the complainant had taken treatment on O.P.D. basis on 19.12.2017 from Dr. Sandeep Kumar of Dhanvantri Tomer Hospital, Bareilly. As per prescription of New Dev Medical Store, Puwaya, the DLA was suffering from B/L Extensive Pulmonary tuberculosis since 27.4.2017, which the DLA did not disclose at the time of proposal.

It is observed from the records that though the insured died within seven days of inception of policy, the evidence produced by the insurer in support of the allegations of the existing disease is not credible, and does not prove conclusively that the insured was ill prior to taking of the policy. Even the prescription of New Dev Medical Store, Puwaya does not have any evidentiary value as it does not have any name and signature of the doctor and even date can not be ascertained. The certificate issued by Dr. Sandeep does not indicate the disease ,patient name, and date .He has used the word “he might have come with difficulties in breathing”. This shows that even he was not sure of deceased illness. Considering the weak and unreliable evidence, the insurer’s decision to repudiate the claim is not justified. The insurer is directed to make payment of death claim under the policy.

AWARD

Taking into account the facts and circumstances of the case and the submissions made by both the parties during the course of hearing, the insurer is directed to make payment of death claim under the policy.


22. The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules, 2017:

a) According to Rule 17(6) of Insurance Ombudsman Rules,2017, the insurer shall comply with the award within thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman.


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. AND UTTARAKHAND

UNDER INSURANCE OMBUDSMAN RULES 2017 OMBUDSMAN – SH. C.S.PRASAD

CASE OF SMT. SUDHA GUPTA V/S LIFE INSURANCE CORPORATION OF INDIA COMPLAINT REF: NO: NOI-L-029-2021-0122

AWARD NO:

1. Name & Address of the Complainant Smt. Sudha Gupta, W/O Late Sh. Rajeev

Gupta

Pratibha Colony, Rambagh, Near Mohan

Nagar Tower, Aligarh, Uttar Pradesh-

202001

2. Policy No:

Type of Policy


208982700

Life Plan

19/19



Late Sh. Sh. Rajeev Gupta

Late Sh. Rajeev Gupta

4. Name of the insurer Life Insurance Corporation of India



Non –Disclosure of Material Facts of

Illness



9. Amount of Claim Rs.1.50 Lakh


11. Amount of relief sought Rs.1.50 Lakh


IOB rules

13.1.d

13. Date of hearing/place On 14.10.2020 at Noida



b) For the insurer Mr. Sushil Sharma, A.O.


16 Date of Award/Order 16.10.2020.

17)Brief Facts of case ;- This complaint is filed by Smt. Sudha Gupta against the decision of LIC of India relating to repudiation of death claim under policy no. 208982700 issued on the life of her husband Late Sh. Rajeev Gupta.

18)Cause of Complaint:- Repudiation of Death Claim of Policy

Complainants argument;- The complainant stated that that her husband had taken a policy bearing no. 208982700 from LIC of India 28.5.2018 for sum assured of Rs.1.50 Lakh on annual mode of payment of premium of Rs.1791/- with policy term of 19 years. She submitted that her husband died on 9.6.2019 at home. The complainant had submitted all the relevant claim forms to the insurer for settlement of death claim. The death claim payment had been repudiated by the insurer on the ground of concealment of previous Illness on 31.1.2020.

Insurers’ argument:- The insurer stated that a policy named Aadhar Stambh bearing no. 208982700 was issued on the life of Late Sh. Rajeev Gupta for sum assured of Rs.1.50 lakh with policy term and premium paying term of 16 years at the age of 51 years on the basis of Aadhar Card and was having mobile shop. The life assured died on 9.6.2019 i.e. after 1 year and 11 days of inception of policy. On investigation of claim it was found that the DLA died due to cancer with difficulty of “Non healing of Ulcer and Neck –Swelling with oral bleeding since 1 year. And was diagnosed “Carcinoma Hard Plate T3N2aMo”. This fact was proved through claim form B-1 .The DLA deliberately did not disclose the material fact regarding his health at the time of taking policy. Had he disclosed these ailments in his proposal it would have affected underwriting decision. Hence death claim was repudiated on the ground of concealment of material facts regarding health on 31.1.2020. The claimant has already appealed to ZCRC, Kanpur. The ZCDRC, Kanpur has upheld the decision vide letter dated 15.9.2020.


20) The following documents were placed for perusal. a) Complaint Letter b) Repudiation Letter c) Policy Document d) SCN 21) Observations and Conclusion;- :- On line hearing in the case was held on14.10.2020.Both

parties appeared for on line hearing and reiterated their submissions. The complainant submitted that her husband had some problem in throat; otherwise he was fit and fine. The insurer submitted that the DLA died due to cancer on 9.6.2019. This fact was proved through hospital treatment form i.e. claim form B-1 .The DLA deliberately did not disclose the material fact regarding his illness at the time of taking policy.

It is nobody’s case that the insured did die of cancer- the complainant does not contest it, and the claim form B1 leaves no doubt about it. The point of dispute is whether the insured was suffering from cancer prior to the policy date, and he deliberately suppressed this material information at the time of taking the policy in May 2018. The treatment papers of Dr. B.R.A. Institute of Rotary Cancer Hospital AIIMS, New Delhi is dated 15.10.2018 which only indicates that the DLA got himself examined in the OPD. Clearly, this treatment was taken after the issuance of the policy in May2018, and these treatment papers also confirm that previously he was not admitted to any other hospital. It is also noted that the investigating officer has himself confirmed in his report that the DLA was suffering from Cancer from September-2018, which is after the inception of policy. The insurer has not adduced any cogent evidence of insured’s illness prior to the inception of policy nor have they produced any evidence to prove mens rea on the part of the deceased insured. Further, the claim form B-1 which is the main evidence of the insurer, contradicts itself

at point 4 and 5. While at point 4, the duration is shown as 1 year, at point 5 the duration is shown as 20-25 days. The insurer is unjustified in repudiating the claim on the basis of the evidence which itself suffers from flaws, and are not convincing enough to conclusively prove that the insured suppressed the information of his being sick with cancer at the time of taking the policy. The insurer is directed to make payment of death claim under the policy

AWARD

Taking into account the facts and circumstances of the case and the submissions made by both the parties during the course of hearing, the insurer is directed to make payment of death claim under the policy


22. The attention of the Complainant and the Insurer is hereby invited to the following provisions of Insurance Ombudsman Rules, 2017:

a) According to Rule 17(6) of Insurance Ombudsman Rules,2017, the insurer shall comply with the award within thirty days of the receipt of the award and intimate compliance of the same to the Ombudsman.


PROCEEDINGS BEFORE



OMBUDSMAN – SH. C.S.PRASAD

CASE OF MRS. MAYA GARG V/S HDFC LIFE INSURANCE COMPANY LIMITED


AWARD NO:

1. Name & Address of the Complainant Mrs.Maya Garg,

W/O Late Sh. Subash Chand Agarwal,

180- Kayasthwada, Lohia Bazar,

Muzaffarnagar. (U.P.)- 251001

2. Policy No:

Type of Policy


20726611

Life , DOC – 20.09.2018

10/10 Years



Sh. Subash Chand Agarwal,

Sh. Subash Chand Agarwal

4. Name of the insurer HDFC Life Insurance Company Limited



Pre-existing disease was not disclosed in

proposal form.


8. Nature of complaint Repudiation of death cliam

9. Amount of Claim Rs. 1,80,000/-

10. Date of Partial Settlement Rs.41,769( Payment of fund value))

11. Amount of relief sought Rs.1,38,231/-


IOB rules

Yes

13. Date of hearing/place 12.10.2020/NOIDA


a) For the Complainant Mr. Mayank Agarwal (Son of Deceased)

b) For the insurer Mr. Kunal Aurora

15 Complaint how disposed AWARD


17)Brief Facts of case ;- This is a complaint filed by Mrs. Maya Garg against HDFC Life Insurance Company Ltd., relating to repudiation of death claim of her husband Late Mr. Subhash Chand Agarwal under Insurance policy No. 20726611. 18)Cause of Complaint:- Repudiation of death claim by Insurance Company.

a) Complainants argument :-The complainant alleged that her husband Late Mr. Subash Chand Agarwal had purchased the above numbered policy with sum assured of Rs. 1,80,000/- on 20.09.2018 from the above Insurance company. Her husband died on 16.10.2019 due to kidney failure. The claimant had submitted the claim documents for settlement of death claim of the insured. The insurance company declined the death claim on 02.12.2019 of her husband with the reason “ From investigations, it was established that the life assured was suffering from Diabetes and Hypertension prior the policy issuance. This was not disclosed in the proposal form . Further, the complainant requested the Claim Review Committee for reconsideration of death claim. But, Claim Review Committee of the said insurance company did not reply in the matter. The complainant has approached Insurance Ombudsman for redressal of her grievance.

b) Insurers’ s argument :- Insurer stated and contended that the insurance company received the proposal form for insurance on 17.09.2018 and relying on the replies/declarations provided by the life assured in the proposal form for insurance, the company had accepted the proposal form and issued policy bearing number 20726611 on 20.09.2018 with sum assured Rs.1,80,000/- with yearly premium of Rs.24,000/- The insurance company had received the death claim form on 11.11.2019 for settlement the Sum Assured against the demise of Life Assured on dated 16.10.2019. The insurance company appointed the investigator to investigate the matter as per the norms of IRDA. The investigator submitted his report on 27.11.2019 to the insurance company and has clearly mentioned that the Life Assured was the known patient of Diabetic, Hypertension, Chronic Kidney Disease and was consuming alcohol from last

20 years. As per the investigation and medical documents available with the company, DLA was taking treatment from AIIMS, Rishikesh for Ca. Tongue. The insurance company repudiated the death claim upon receiving the report from the investigating agency and on the ground of facts which were revealed during investigation. The said claim was repudiated on the ground of Non-disclosure of Health Conditions (Diabetic and Hypertension) and repudiation letter dated 2.12.2019 was also escalated at the address of the claimant. The above mentioned medical history is prior to the policy issuance. The insured had not disclosed his medical adversities at the time of availing the policy. The insurance company repudiated the death claim of the insured on the above said grounds and refunded the paid premiums on 4.12.2019 to the claimant.


20) The following documents were placed for perusal. a) Complaint Letter b) Repudiation Letter c) Policy Document d) SCN 21) Observations and Conclusion : Both the parties were present for on line hearing on 12.10..2020. During the course of hearing, the son of deceased Mr. Mayank Agarwal claimed that the deceased life assured was not patient of Diabetes and hypertension.. His father died on 16.10.2019 due to kidney failure.. The nominee, his mother Mrs. Maya Garg submitted the claim forms for settlement of death claim. The insurance company denied the claim. During the course of hearing, the insurance company argued that the insured was the patient of diabetes and Hypertension prior to taking the policy. As per Preoperative Assessment Chart of AIIMS Rishikesh dated 30.8.2019:- Past History:- i) DM & CAD – 10 Years ( Irregular medicine for diabetes) ii) HTN – 10 Years iii) CKD – 10 months Present History:- Alcohol consumption – 20 years. The insurance company produced the copy of proposal form, which the deceased had replied in negative in his personal details. The insured had not disclosed his medical adversities at the time of availing the policy. The insurer refunded the payment of fund value of Rs. 41769/ to the claimant/nominee. It is observed from the submitted records that the Preoperative Assessment Chart of AIIMS Rishikesh dated 30.8.2019 shows that the insured was habitual alcoholic for the last 20 years and DM & CAD, HTN from 10 years and died on 16.10.2019 due to kidney failure. The insured had given negative answer related to his health details in the proposal form. It is evident that the insured had not disclosed his medical conditions, which are material facts for insurer at the time of taking the policy. I find no reason to interfere with the decision of the Insurance Company.

AWARD

Taking into account the facts and circumstances of the case and the submissions made by both the parties during the course of hearing, I find no merit in the complaint I see no reason to interfere with the decision of the insurance company.

The complaint is dismissed.


PROCEEDINGS BEFORE



OMBUDSMAN – SHRI C. S. PRASAD

CASE OF MR. PAWAN KUMAR V/S BAJAJ ALLIANZ LIFE INSU. CO. LTD.


:1. Name & Address of the Complainant Mr. Pawan Kumar

Village Mahavatpur Jatpura

BIJNOR U P - 246747

M- 6395438038

2. Policy No:

Type of Policy


36107982

LIFE

5/10



Late Ankita Kumari

Late Ankita Kumari

4. Name of the insurer Bajaj Allianz Insurance Co. Ltd.

5. Date of Rejection 14-12-2018

6. Reason for rejection Non disclosure of pre existing disease



9. Amount of Claim


11. Amount of relief sought Death Claim payment


IOB rules

Yes



a) For the Complainant Mr. Pawan Kumar

b) For the insurer Ms Swati Seth



17 . Brief Facts of the case : The complainant Mr. Pawan Kumar purchased a policy for his daughter Ms Ankita on 18/07/2017 from Bajaj Allianz Life Insurance Company. The life assured expired on 7-08-2017 due to sudden heart attack. The complainant had submitted the papers for payment of death claim. The insurer stated that the life assured expired on 5-07-2017, and policy was purchased fraudulently after 13 days of the death of the life assured. The complainant has stated that he had submitted all papers related to death claim, showing death date 5-08-2017 and wants the settlement of the claim.


Complainant’s argument : The complainant purchased the policy for his 14 year old daughter Ankita on 18/07/2017 by submitting required papers for issuing the policy. The policy was purchased for Rs.4.8 lacs with half yearly premium of Rs 23,759/-. On 5-8-2017 she died due to sudden heart failure at their residence. The complainant had submitted the claim papers on but the insurer rejected the claim on 14-12-2018, stating that the assured died before purchasing the policy. The complainant sent us the complaint on 11-10-2019 about rejection by insurance company. He was advised to send complaint to GRO first. Then again we received the complaint on 7-07-2020.The complainant submitted the death certificate with date of death 5-08-2017 and place of death was Thakurdwara, Moradabad. Insurer’s argument : The insurer has stated that the policy was issued on 18-07-2017. As per death certificate, the assured died on 5-08-2017. The death was within 13 days of issue of policy. Being a very early claim, the investigation was to be done. The investigation officer has mentioned in his report that assured died on 5-07-2017 by burning herself. The officer enquired with the Anganwadi worker and the Gram Pradhan of the village; first of all they refused to give any statement. But when the investigation officer made video, they agreed and gave written statement. They mentioned in their statements that assured expired on 5-07-2017, by self burning at her residence. The officer submitted the copy of family register showing date of death 5-07-2017 and the death record register of the village showing the death due to burning. The complainant’s malafide intention is clearly obvious in this case. Concealment of any material information or providing any false or incorrect information is a violation of the insurance contract. The claim has been repudiated in view of breach of the terms and conditions of the insurance contract.

19. Reason for Registration of Complaint:

Scope of Insurance Ombudsman Rule 2017.

20. Following documents were placed for perusal:

1. Complaint letter.

2. Copy of proposal forms and IDs

3. SCN

21. Observation and conclusion :

Both the parties appeared for online hearing and reiterated their submissions. The complainant urged that his 14 year old daughter died on 5-08-2017 at their residence due to

sudden heart attack. They did not consult any doctor for heart attack. The proper death certificate from Birth & Death department Thakurdwara was submitted by the complainant. The insurer stated that being an early claim they got the case investigated and report has shown that assured had died of 5-07-2017 by burning herself. The investigating officer has submitted the written statement of Anganwadi worker and village Pradhan confirming the death by self burning on 5-07-2017 in the village.

I have examined the documents exhibited as evidence and oral submissions made by both the parties. It is observed that while the death of life assured is claimed by heart attack at the age of 14 years, there was no consultation of Doctor. It is surprising . Secondly, in complainant’s letter, it was mentioned that death had occurred on 5.8.17 at their residence, but the Death certificate was issued on 10-09-2018 from Thakurdwara, 85 km away from their residence . This creates a doubt of foul play in the matter, but the death certificate issued by birth and death department confirming date of death as 5-08-2017 cannot be ignored also. During hearing, the insurer was asked to submit within 7 days a certificate of cancellation of the death certificate from Birth & Death department on the basis of Gram Pradhan’s and panchayat’s written statements. The Insurer submitted the old DC with signature and stamp of above mentioned officers, who confirmed the date of death was 5-07-2017. The insurer also informed us that on assurance from them of not panelizing, the agent accepted the involvement in the fraud. The insurer has applied to B&D department and informed us that the action by the department will be taken in some time. The circumstances of the case and documents submitted do create a reasonable suspicion about the date of death. However, to ascertain the exact and unassailable evidence regarding the date of death of the deceased, the case needs to be thoroughly investigated by civil/police authorities. This is beyond the jurisdiction of this office. The complaint is dismissed.

Place: Noida. C.S. PRASAD

Dated: 20.10.2020 INSURANCE OMBUDSMAN

(WESTERN U.P. & UTTARAKHAND)


UNDER INSURANCE OMBUDSMAN RULES 2017 OMBUDSMAN – SHRI C. S. PRASAD

CASE OF KAMLA DEVI V/S BHARTI ASXA LIFE INSURANCE CO. LTD. COMPLAINT REF: NO: NOI-L-008-2021-0114

AWARD NO:

1. Name & Address of the Complainant Mrs Kamla Devi W/O Ashok Kumar

C/O Sh Ramswaroop H.No- 575

Laxman Puri, Brahampuri

Meerut UP- 250002

2. Policy No:

Type of Policy


501-6878838

LIFE

12 Years



Mr. Ashok Kumar

Mr. Ashok Kumar

4. Name of the insurer Bharti Axa Life Insurance CO.

5. Date of Rejection No reply

6. Reason for rejection Repudiation of death claim


8. Nature of complaint repudiation

9. Amount of Claim

10. Date of Partial Settlement nil



IOB rules

Yes



a) For the Complainant Mrs Kamla Devi

b) For the insurer Mr Harpal Singh



17 . Brief Facts of the case : The complainant’s husband Sri Ashok Kumar purchased this policy on 12-03-2018 . He died due to sudden Heart attack on 24-04-2019. The complainant submitted the death claim but the insurer rejected the claim stating the life assured was suffering from Diabetes before purchasing the policy. The complainant has submitted her complaint to ombudsman office on 23-07- 2020.


Complainant argument : The complainant stated that when her husband purchased the policy, he was hale and hearty. He had no health issue at that time and he was not taking any medicine. On 24-04-2019, he suffered from a sudden heart attack and died,and they could not take him to doctor. She has urged that the insurer has rejected the claim stating that assured was suffering from Diabetes before purchasing the policy and the fact was not disclosed to the insurance company . She has stated that as per her knowledge her husband was not suffering from any disease . The enquiry officer had visited her place and asked for some identification proofs and told her that everything was ok and she would receive the claim but insurer has rejected the claim without any reason..

Insurer’s argument : On 09.07.2019, the insurance company was in receipt of death claim of Shri Ashok Kumar from the complainant informing that the Life assured died on 24.04.2019 due to heart attack. That as death of life assured occurred within 1 year 4 months from date of issuance of the policy, as per Section 45 of the Insurance Act, insurance company was entitled to investigate the veracity of the claim. After careful evaluation of the records obtained by the Company, during the claim processing, it was revealed that the Life Assured had obtained the policy through fraud by active concealment of material facts that Mr. Ashok was a known case of Diabetes Mellitus since 2017 i.e. prior to the signing of the proposal for Insurance and was

under treatment for the same. Thus it was revealed that the Company has been misled to issue the aforesaid policy on the life of Mr. Ashok. The insurer has submitted medical documents procured from Sardar Vallabhbhai Patel Hospital, Meerut in the name of Life Assured wherein history of diabetes mellitus suffered by life assured has been categorically mentioned. The company is, therefore, satisfied that there has been a deliberate attempt to defraud the Company for gain of a huge sum. The Company in view of the above facts stated that it is evident that the complainant herein has filed the present complaint with malafide intentions to gain undue advantage from the insurer , since the company has rightly repudiated the claim due to suppression of material facts. Hence present complaint should be dismissed in favor of insurance company.

19. Reason for Registration of Complaint:

Scope of Insurance Ombudsman Rule 2017.

20. Following documents were placed for perusal:

1. Complaint letter.

2. Copy of proposal forms and IDs

3. SCN

21. Observation and conclusion :

Both the parties appeared for online hearing and reiterated their submissions. The complainant urged that her husband died at their residence due to sudden heart attack. The enquiry officer visited their home and was asking money for claim settlement in her favor. As per complainant, as she had refused to give any money, so the investigator had submitted a negative report and her claim was rejected. She said that her husband was healthy. He did not have any disease.

The insurer stated that being an early claim they got the case investigated by two investigating companies . The first company , Virtual I. Services submitted their report wherein it was mentioned that on enquiring from the neighbors, the assured was a shoe maker, and was suffering from high diabetes and eyes problem developed due to diabetes. He was admitted to Meerut Medical College. The medical college refused to share the treatment papers, as per the hospital’s rules. The second investigation was done by Probe India. They also stated that assured died due to his health problems. The investigation officer was told by assureds’ daughter that her father was sick and was taking treatment from Sardar Ballabh Bhai Patel Hospital Meerut since last two years. The investigator also produced the treatment papers of the assured, which they had procured from the assureds’ family only. I have examined the documents exhibited as evidence and oral submissions made by both the parties. The insurer has got the case investigated by two investigating companies. Both have stated in their reports, that the assured was suffering from high Diabetes. The statement of assureds’ daughter has also been submitted wherein she has confirmed that her father was taking treatment form Sardar vallabh Bhai hospital. The treatment papers of the hospital suggest that assured was under treatment before purchasing the policy and did not disclose the fact , which is a breach of contract. Hence the insurer’s decision to repudiate the claim is justified and request of the complainant for settlement of claim is set aside.

AWARD

Taking into account the facts and circumstances of the case and the submissions made by both the parties during the course of hearing, the insurer’s decision for repudiation of the claim on the basis of non disclosure of pre existing disease is justified, and the request of the complainant for settlement of claim is set aside.

The complaint is treated as closed accordingly.




CASE OF SH. BHANU PRAKASH V/S PNB MET LIFE INSURANCE COMPANY COMPLAINT REF: NO: NOI-L-033-2021-0142

AWARD NO:

1. Name & Address of the Complainant Sh. Bhanu Prakash

R/O Village Danpur, Islam Nagar

Budaun, Uttar Pradesh- 202523

2. Policy No:

Type of Policy


22977518

Life Plan

20/10



Late Sh. Surjeet

Sh. Bhanu Prakash

4. Name of the insurer PNB Met Life Insurance Company Limited


6. Reason for repudiation Death prior to proposal



9. Amount of Claim Rs.5 Lakh


11. Amount of relief sought Rs. Lakh


IOB rules

13.1.d




b) For the insurer Sh. Arijit Basu, Sr. Legal Manager



17)Brief Facts of case ;- This complaint is filed by Sh. Bhanu Prakash against the decision of PNB Met Life Insurance Company Limited relating to repudiation of death claim under policy number 22977518 issued on the life of his son Late Sh. Surjeet.

18)Cause of Complaint:- Repudiation of Death Claim under the policy.

a) Complainants argument ;- The complainant stated that he had taken a policy on the life his son Sh. Surjeet on 25.7.2019 for sum assured of Rs.5 Lakh on. His son fell down from the upper floor of the house and expired on the spot. The complainant filed the death claim with the insurer.

The insurer has repudiated payment of death claim on the ground that the date of Birth differs in Aadhar /Marksheet and the life assured expired before the proposal.

b) Insurers’ argument:- The insurer in their SCN stated that Late Sh. Surjeet, deceased life assured after completely understanding the terms and conditions of our product had voluntarily applied for a policy by filling up the proposal form on 13.7.2019 on half yearly payment of premium of Rs.23881/- for sum assured of Rs.5 Lakh. On the basis of proposal form along with initial premium a policy number 22977518 was issued on 25.7.2019 for policy term of 30 years and premium paying term of 10 years. The insurer received the death intimation under the policy informing death of DLA on 25.8.2019 i.e. death of the assured with in 1 month of taking policy. The KLCR Investigation Pvt. Limited service was appointed as an investigator to investigate the claim lodged by the complainant. The said investigator found that on 25.6.2019, the insured went to Gram Daulatpur, Badaun to attend a marriage and after dinner

he fell from the roof and was rushed to Aligarh for immediate treatment where he died on 28.06.2019( prior to policy issuance)during treatment. His cremation was done in Danpur. The policy was purchased by fraudsters by introducing another personality in place of insured. Since there is mismatch in the date of birth in School Certificate and Aadhar Card/ Voter card/ Voter ID Card Prima facie, the Aadhar belongs to some other person. The DLA had already died prior to issuance of the policy and the complainant / nominee fraudulently obtained the policy. As such insurer is not liable to pay death claim as per terms and conditions of policy. The death claim was rejected vide letter dated 7.1.2020 and the same was communicated to the complainant.



21) Observations and Conclusion On line hearing in the case was fixed on26.10.2020. Both the complainant and insurer attended the hearing and reiterated their submissions. The complainant submitted that he had taken a policy on the life his son Sh. Surjeet on 25.7.2019 for sum assured of Rs.5 Lakh. His son fell down from the upper floor of the house and expired on the spot. The complainant filed the death claim with the insurer. The insurer has repudiated the death claim payment on false grounds.

The insurer submitted that they received the death intimation under the policy informing death of DLA on 25.8.2019 i.e. death of the assured with in 1 month of taking policy. During investigation it was found that the policy was purchased by fraudsters by introducing another personality in place of insured. Since there is mismatch in the date of birth in School Certificate and Aadhar Card/ Voter card/ Voter ID Card Prima facie, the Aadhar belongs to some other person. The DLA had already died prior to issuance of the policy and the complainant / nominee fraudulently obtained the policy. The company has filed a police complaint in the captioned matter

Recommendation

Taking into account the facts and circumstances of the case and the submissions made by both the parties during the course of hearing, the complaint is dismissed.







CASE OF SH. SANDEEP V/S PNB MET LIFE INSURANCE COMPANY COMPLAINT REF: NO: NOI-L-033-2021-0160

AWARD NO:

1. Name & Address of the Complainant Sh. Sandeep Gupta

S/O Sh. Jagannath Prasad

Mohalla- Jabtaganj

Masjid –Najibabad, Bijnor

Uttar Pradseh--246763

2. Policy No:

Type of Policy


22986375 and 22739643

-----------Life Plan-----------------------

20/10 30/30



---------------Sh. Arvind Gupta--------------

----------------Sh. Arvind Gupta------------

4. Name of the insurer PNB Met Life Insurance Company Limited



Death Prior to Proposal



9. Amount of Claim Rs.4 Lakh Plus Rs.3 Lakh

10. Date of Partial Settlement ------NIL-----------------------

11. Amount of relief sought Rs.7 Lakh


IOB rules

13.1.b




b) For the insurer Sh. Arijit basu, Sr. Legal Manager



17)Brief Facts of case ;- This complaint is filed by Sh. Sandeep Gupta against the decision of PNB Met Life Insurance Company Limited relating to repudiation of death claim under policy number 22986375 and 22739643 issued on the life of his brother Late Sh. Arvind Gupta.

18)Cause of Complaint:- Repudiation of Death Claim under the policies.

Complainants argument. ;- The complainant stated that his brother Late Sh. Arvind Gupta had taken policy number 22986375 and 22739643 on his own life on 22.7.2019 and on 4.12.2018 for sum assured of Rs.4 Lakh and Rs.3 Lakh respectively . His brother died suddenly on 17.9.2019 due to heart attack. The complainant filed the death claim with the insurer. The insurer has repudiated payment of death claim on the ground that the life assured expired before the proposal.

Insurers’ argument:- The insurer in their SCN stated that Late Sh. Arvind Gupta, deceased life assured after completely understanding the terms and conditions of our product had voluntarily applied for two policy bearing number by filling up the proposal form on half yearly payment of premium of Rs.39216 and Rs.30000/- for sum assured of Rs.4 Lakh and 3 lakh. On the basis of proposal form along with initial premium policy number 22986375 and 22739643 were issued on 22.7.2019 and on 4.12.2018. The insurer received the death intimation under the policy informing death of DLA on17.9.2019 i.e. death of the assured with in2 months and 10 months of taking the policies.

The BLUE Syp Inc Investigation service was appointed as an investigator to investigate the claim lodged by the complainant. The said investigator found that the DLA was operated for Kidney ailment and his health was critical and worsening in the past one year but unable to procure any medical records. Later DLA died on 18.11.2018due to kidney disease. The written statement of DLA’S sister confirms that DLA was staying at Dehradun for 10 years and died on 18.11.2018 which prior to issuance of policy.

The DLA had already died prior to issuance of the policy and the complainant / nominee fraudulently obtained the policy. As such insurer is not liable to pay death claim as per terms and conditions of policy. The death claim was rejected vide letter dated14.1.2020 and the same was communicated to the complainant.



21)Observations and Conclusion;- :-On line hearing in the case was fixed on26.10.2020. Both the complainant and insurer attended the hearing and reiterated their submissions. The complainant submitted that his brother Late Sh. Arvind Gupta had taken 2 policies on his own

life. His brother was in private job, died suddenly on 17.9.2019 due to heart attack and had no disease. The insurer has repudiated payment of death claim on false grounds.

The insurer submitted that the written statement of DLA’S sister confirms that DLA died on 18.11.2018 due to kidney problems, which is prior to issuance of policy, therefore they rejected death claim payment.

The insurer submitted that some scamsters had taken the policy fraudulently and considering the facts found during the investigation and due to criminal nexus & scammers working in the market who are taking policies in the name of non-existent person, the company has decided to file police complaint in the captioned matter

I observe that the insurance company has repudiated the claim on the basis of reasonable doubts. The insurance company confirmed that they have filed a police complaint on26.4.2020 vide complaint no. 3163204012000003 against the complainant. Since the matter is being investigated and dealt with by police authorities, the present complaint is dismissed.

Recommendation

Taking into account the facts and circumstances of the case and the submissions made by both the parties during the course of hearing, the complaint is dismissed.







CASE OF MRS. FAEEMA V/S MAX LIFE INSURANCE COMPANY COMPLAINT REF: NO: NOI-L-032-2021-0116

AWARD NO:

1. Name & Address of the Complainant Smt. Faeema

W/O Late Mohd. Yameen, Ward No.2

Shiv Nagar, Sultanpur Patti

Udham Singh Nagar,

Uttarakhand-244713

2. Policy No: 310075924

Type of Policy/Duration of policy/Policy period Life Plan



Late Sh Mohammad Yameen

Late Sh. Mohammad Yameen

4. Name of the insurer Max Life Insurance Company Limited


6. Reason for repudiation Pre Existing Disease





11. Amount of relief sought RS. 10,53,441/-

12. Complaint registered under IOB rules 13.1.b

13. Date of hearing/place On 26.10.2020


a) For the Complainant Smt. Faeema

b) For the insurer Ms. Aanchal Yadav



17)Brief Facts of case ;- This complaint is filed by Smt. Faeema against the decision of Max Life Insurance Company Limited relating to repudiation of death claim under policy number 310075924 issued on the life of her husband Late Sh Mohammad Yameen.

18)Cause of Complaint:- Repudiation of Death Claim under the policy.

Complainants argument ;- The complainant stated that her husband Late Sh. Mohammad Yameen had taken a policy number 310075924 from Max Life Insurance Company Limited on 24.10.2017 on annual mode of payment of premium. She further stated that her husband died on 25.6.2019 during treatment in the Dr. Sushila Tiwari Government Hospital, Haldwani, Nainital. The complainant had submitted the entire claim documents to the insurer. The insurer has repudiated payment of death claim on 31.3.2020 on the ground of pre-existing disease.

Insurers’ argument:- The insurer stated that a policy bearing number 310075924 was issued on the life of Mohammad Yameen on 24.10.2017on annual mode of payment of premium on

the basis of duly executed proposal form. The insurer received claim intimation on 24.2.2020 stating death of the life assured on25.6.2019. Since it was an early claim it was investigated and it was found that the DLA was suffering from Chronic Myeloid Leukemia since 8 years and was taking treatment from two Government hospitals of Delhi i.e. AIIMS & GB Pant. The DLA did not disclose the same at the time of proposal and concealed his previous illness at the time of taking policy. Hence the death claim payment under the policy was repudiated.


20) The following documents were placed for perusal. a) Complaint Letter b) Repudiation Letter c) Policy Document d) SCN 21) Observations and Conclusion: Both the parties appeared for on-line hearing on

26.10.2020. The complainant submitted that her husband died on 25.6.2019 but the insurance company denied the payment of claim. The insurance company submitted that the claim was rightly repudiated as the deceased deliberately did not disclose his pre existing disease at the time of proposal. The insurance company submitted copies of the treatment record from the hospital the deceased took treatment during his terminal illness in their support. In these records, there is a mention that the deceased was a patient of Chronic My Chronic Myeloid Leukemia since 8 years and was taking treatment from two Government hospitals of Delhi i.e. AIIMS & GB Pant.

It is observed from the papers on record that the IPD papers from Dr. Susheela Tiwari Government Hospital, Haldwani are of the current treatment but the mention of the previous illness is mentioned not only as a part of the record but it formed the basis of treatment and surgery and was referred to for multiple times during his hospitalization from 10.6.2020 till his date of death. The claimant has also not disputed the treatment records of Dr. Susheela Tiwari Government Hospital, Haldwani .Therefore, it cannot be ignored. The mention that he was taking chemotherapy indicates that he was in the knowledge of his illness and did not disclose it at the time of proposal. The action of insurance company in repudiating the claim cannot be faulted with. I see no reason to interfere with that.

AWARD

Taking into account the facts and circumstances of the case and the submissions made by both the parties during the course of hearing, I see no reason to interfere with the decision of the insurance company. The complaint is dismissed.





AWARD NO.IO/KOC/A/LI/0063/2020-2021

PROCEEDINGS OF

THE INSURANCE OMBUDSMAN, KOCHI

(UNDER RULE NO. 13(1)b READ WITH RULE 14 OF

THE INSURANCE OMBUDSMAN RULES, 2017)

Complaint No. KOC-L-041-2021-0052

PRESENT: Ms. POONAM BODRA

INSURANCE OMBUDSMAN, KOCHI.

AWARD PASSED ON 07.10.2020

1. Name and Address of the

complainant

: Mrs. Shobha Vijayan

Olympia, T C 3/1512, Lakshmi

Nagar, Kesavdasapuram,

Thiruvananthapuram

2. Policy Number

:


: Mr. Vijayan

4. Name of the Insurer

: SBI Life Insurance Co. Ltd.

5. Date of receipt of Complaint

: 17.06.2020

6. Nature of complaint

: Rejection of Death claim

7. Amount of relief sought : --

8. Date of hearing

: 08.09.2020

9. Parties present at the hearing

a) For the Complainant

: Ms. Sobha Vijayan (on line)

b) For the Insurer : Mr. M Moni (online)

AWARD

This is a complaint filed under Rule 13(1)b read along with Rule 14 of the Insurance

Ombudsman Rules, 2017. The complaint is rejection of Death claim.

1. Averments in the complaint are as follows:

The complainant states that her husband Late Vijayan, who died on 23.09.2008 has availed a housing loan of Rs 12 lakhs from SBI, Specialized Personal Banking Branch, General Hospital Road, Trivandrum in the year 2004 (Housing Term Loan Account No 10026725435) . Along with the said loan, the late Vijayan availed insurance for the entire coverage of the loan amount (SBI Life) as well. Late Vijayan was paying the loan installment as well as the premium amount for the insurance coverage without any default while he was alive due, upto April 2009. Thereafter,

the complainant made a representation to the Bank authorities on 08.05.2009 along with all relevant papers requesting to set off the rest of the loan amount by the insurance coverage amount as per the terms of the Insurance policy

To the utter dismay of the complainant, her representation was not given any response by the Bank authorities and also coercive steps were taken against the property of the complainant.

Hence the complainant has sent lawyer notice on 12.11.2010 seeking to recover the loan amount from the insurance coverage. The complainant’s repeated requests fell on deaf ears and revenue recovery proceedings under SARFAESI Act was initiated without giving any response to the complainant regarding her request for set off of the loan amount from the Insurance Coverage.

The complainant states that a much belated notice dated 20.10.2011 was issued by the Bank observing that life of the borrower falls beyond the standard and subsequently the premium of Rs. 81,516/- was refunded by the Insurance Company and was credited to the loan account. It was only in 2011 that any intimation regarding the lapse of insurance policy was given to the complainant .The Bank as well as the Insurance Company has deliberately kept the complainant in the dark regarding the same all through. The complainant has taken two other housing loans as well. It is to be pertinently noted that they are not willful defaulters as they have made due payments of all the loans without fail until 2009 and it was only under the bonafide and legitimate expectation that the rest of the loan amount will be meted out from the insurance policy that they didn’t make further payments. The other two loans though being repaid

regularly, have also been classified as bad loans along with the account classified as NPA.

The complainant assertively reiterates that no intimation was forthcoming from the part of the Insurance Company regarding the cancellation of the policy. Though the Insurance Company claims that the premium has been refunded and credited to the loan account, till date no

intimation in that regard has been given. The complainant was under the bonafide belief that the loan amount will be paid by the Insurance Company to the Bank. If at all the Insurance policy was lapsed later due to the reasons claimed by insurer, it is highly arbitrary as to why then payments towards premium were taken from the complainant’s husband.

The complainant state that they have been put into immense mental trauma and emotional turmoil by the lackadaisical attitude of your authorities. The complainant had to go through rigorous litigation, as instead of accepting the balance amount due under the loan from the Insurance Company, the Bank has begun to harass the complainant by initiating revenue recovery proceedings.

The complainant states that the default in the payment from 2009 onwards was solely

attributable to the lack of proper intimation from the Insurance Company regarding the cancellation of the policy. The complainant also asserts that there was no proper intimation regarding your claim as to the refund of the premium amount as well.

The complainant urges to provide them with the necessary documents evidencing the cancellation of the Insurance policy, if any and the reasons for such cancellation without giving proper notice and intimation. The complainant wants a clarification regarding the claim that the Insurance premium was refunded and credited to the Loan account.

2. The respondent insurer entered appearance and filed a self contained note. It is submitted that the present complaint is regarding non settlement of claim amount on the Life of Mr. Vijayan under Master Policy No. 83001000203. It is humbly submitted that the Deceased, Mr.

Vijayan had applied for SBI home Loan Insurance scheme group insurance vide Membership Form dated 08.08.2004 under Loan Account bearing no. 01593005543 along with DD dated 08.08.2004 for Rs. 81516/- under Master policy bearing no. 83001000203 and the same was received on 16.08.2004. Based on the membership form and as per the risk assessment parameters of the Company, the company requested the deceased Life assured Mr. Vijayan to undergo medical examination.

A further medical requirement dated 03.09.2004, i.e. Treadmill Test (TMT) and Health questionnaire was raised. The health questionnaire dated13.03.2005 was received on 19.3.2005 which is evident from the inward seal on the same.

However, the TMT report requested in was not received. Since the Treadmill Test (TMT) report

was not received, a letter dated 30.03.2005 was again sent informing inability to take a decision on the insurance proposal.

However, the findings from the TMT were adverse, and hence the deceased was found not insurable. Accordingly, the proposal deposit was refunded vide DD bearing no. 342552 dated 30.11.2005 for Rs. 81,516/-.

The refund amount was credited into the loan account as early as on20.5.2006 by the Bank.

As the medical requirements were not submitted by Mr. Vijayan, the proposal did not culminate into policy and insurance cover was never granted to Mr. Vijayan is reported to have died on 23.09.2008. Hence, the claim was repudiated as there was no concluded contract as on

date of death. The decision of the company is as per the terms and conditions of the policy which is just and legal and hence the complaint is liable to be dismissed on this ground alone.

The deceased Mr. Vijayan is reported to have died on 23.09.2008 and the complaint is filed in 2019, after a gap of 11 years. Hence the complaint is not maintainable due to willful delay and

laches and also hopelessly barred by limitation.

It is submitted that the SBI Life Company Limited has issued a Master Policy in the name of State Bank of India covering the eligible Borrowers of SBI. A copy of master policy dated9.10.2003 bearing no. 83001000203 is enclosed for reference. Insurance cover is not automatic to every member of the group. The risk on each individual is assessed and if the risk cover is accepted, the insurance cover will be granted and a certificate of insurance is issued to the members so covered under the Master Policy. If the proposer is not found insurable, the insurer may decline the proposal. The Master Policy contains the terms and conditions of the Insurance cover. The individual members of the group who are covered by the Group Scheme are issued “Certificate of Insurance”(hereinafter referred to as the COl) as evidence of their

membership of the Group Scheme and of being covered by the Master Policy.

The findings from the TMT were adverse. Hence, the Deceased was not found insurable based on the finding of the TMT. Hence, the proposal deposit was refunded vide DD bearing no. 342552 dated 30.11.2005 for Rs. 81,516/-. 14.It is clearly evident that the Bank has confirmed [vide their letter dated 30.03.2019 the receipt of the refund of the proposal deposit in the loan account on 20.05.2006 itself and thus the Deceased was aware of the fact that he was not insured by the Respondent Company.

The Deceased has not shown any further interest in getting the insurance cover. It is submitted that the refund was made nearly 2 years before the death of Mr. Vijayan. When a proposal was rejected and the party who made the proposal was aware of rejection of his proposal and

refund of the initial proposal deposit during his life time, his successors have no locus standi whatsoever to presume existence of a contract or deemed existence of a contract. The consideration for the proposed contract of insurance was refunded to the Deceased during his life time and thus there was no consideration and the proposal became invalid and thus the Petitioners cannot claim that there was an existence of contract of insurance, that too, when they were not parties to the proposal for insurance at all. Any presumption of existence of a

contract against the facts on record also amounts to the violation of Doctrine of free consent and unilateral imposition of a liability under a non-existing and hypothetical contract.

The insurance cover is not automatic for loan borrowers. The fact that a home loan has been granted does not result in insurance cover automatically. Thus the petition is not maintainable.

In the instant case, the Deceased was not granted any insurance cover and thus was not issued any Certificate of Insurance and thus it is evident that the Deceased was not insured at all by the Company. The complainant is demanding the performance of a contract which did not exist. Hence the complaint is liable to be dismissed.

SBI LIFE hereby denies all the allegations in the complaint as false. In the light of the above facts it is therefore prayed that the Honorable Ombudsman may be pleased to dismiss the complaint on merits and as well as on the basis of the documentary evidences placed on record.

3. I heard the complainant and the respondent Insurer. The complainant submitted that the points mentioned in the averments and also quoted a Supreme Court case in similar lines. The complainant submitted that only in 2011 it was informed that the policy was not accepted by

the company. There is an enormous delay by the company and requested to honor the claim and set off the loan. The respondent Insurer submitted that the points in the averments and

further mentioned that the amount accepted was proposal deposit and it was refunded on 31.11.2005 vide DD bearing no 342552 for Rs.81516/- once the proposal was rejected on medical grounds. It was clearly mentioned that the amount paid towards SBI life insurance has

been refunded in the loan account on 20.5.2006 .The proposer Mr.Vijayan died on 23.9.2008 and its clear that the proposal amount was accounted during the lifetime of Mr.Vijayan. The company further submitted a letter dated 30.3.2019 issued by bank which confirmed the receipt of the proposal deposit in the loan account on 20.2.2006 itself which again proves that the Deceased was aware of the fact that he was insured.

4. The risk of the life of the insured for a consideration amount comes in the form of premium. Here the consideration for the proposed contract of insurance was refunded during the life time of the policy holder for medical reasons and hence the proposal has become invalid. As per the terms of the policy the complaint is not sustainable and hence dismissed.

In the result, an AWARD is passed for Dismissal of the complaint.

Dated this the 7th day of October 2020.

Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF


(UNDER RULE NO. 13 1(b) READ WITH RULE 14 OF







complainant

: Mrs. S. SALINI

W/o. (late) Solanky Krishnan,

Thavalam House, Karippoor

P.O.,Nedumangad, Trivandrum 695

541.

2. Policy Number

: 20280891


: Mr. Solanky Krishnan


: HDFC Standard Life Insurance Co.

Ltd.


: 10.08.2020


: Denial of death claim


: --

8. Date of hearing

: 08.10.2020


c) For the Complainant

: Ms. S Salini (online)

d) For the Insurer : Mr. Vinay(online)

AWARD

This is a complaint filed under Rule 13 1(b) read along with Rule 14 of the Insurance Ombudsman Rules, 2017. The complaint is Denial of death claim. The complainant, Mrs. S. SALINI is the policyholder.


The complainant stated that they had an insurance policy for Rs.900000 with the respondent insurer to cover the housing loan availed Rs1500000 in 2018. The policy holder died on

25.10.2019 due to heart attack. This was intimated to the insurance office. On 15.12.2019 a person from the company visited home and all the requirements , medical reports for the past

5 years were handed over To Mr.Rajendran and he told that it’s difficult to get the claim but can be done if some bribe is paid. Since it’s a genuine claim it was not entertained. After waiting for a while when there was no response the complainant contacted the respondent insurer. It was

informed that the claim was rejected. Simultaneously the claim submitted in HDFC Ergo was settled for Rs.600000 and it was adjusted to the Housing Loan. Inspite of sending the entire documents to claim the life insurance on 18.3.2020 but no response .Then it was lockdown. In July the complainant approached the respondent office in Triruvanthapuram. Then it was informed that the claim was rejected on 26.12.2019 due to the reason that the heart attack and had diabetes.

Certain points mentioned in the complaint letter.

During the issue of policy all the details were given. No question about diabetes was asked. Was diabetic and was maintaining proper diet and sugar was in normal range. Produced all the medical reports. A detailed report by Dr.Prabha cardiologist was submitted on 3.2.2020. While

admission also the blood sugar was 86 and the cause of death is Heart attack. The claim was rejected without any proper investigation and submitted all the reports for the forum for reference.

2. The respondent insurer entered appearance and filed a self contained note. It is submitted that outset, we emphatically deny all the allegations that are set out in the complaint except those that are specifically admitted herein. It is stated that the deceased life assured Solanky Krishnan had taken SL Pro-Growth Flexi bearing No.20280891 valid from 31st March 2018 for a sum assured of Rs.9,00,000/- . It is stated that the complainant had sum assured of Rs.9,00,000/- . It is stated that the complainant had assigned the policy benefits to M/s. HDFC Ltd. The premium paying term and policy term was for 10 years. It is stated that the policy coverage was provided on basis the declarations made by the deceased life assured under the

proposal forms as duly submitted to us. Therefore now the legal heirs of the Deceased life assured cannot question on the veracity of the declarations as made by the deceased life assured during his life time.

It is further stated that the claimant nominee Mrs.Shalini had made a claim under the said policy stating that the life assured Solanky Krishnan expired on 25.10.2019 due to coronary

artery disease and sought for payment of the sum assured. We investigated into the claim being made and it transpired from the deceased life assured was treated at Medical College Thiruvananthapuram as the OP record shows that life assured was suffering from Type 2 DM x 10 years, as the same was a significant non-disclosure, as the outpatient record dated 12.10.2019 clearly showed that the life assured as suffering from Diabetes Mellitus for last ten

years and died whilst undergoing treatment for heart ailment as the life assured suffered from diabetes even before the inception of the policy.

The complainant also admits that the her husband was suffering from diabetes since last 10 years in the complaint filed before this Hon’ble office, it is stated that the life assured did not disclosed about this Hon’ble office, it is stated that the life assured did not disclosed about concealing the material fact related to the past aliments, which significant bearing on the mortality risk of the life assured. Therefore the argument that the diabetes was under control at the time of taking policy is not a valid and relevant here, further diabetes is a life-time disease whose prevalence gradually increases, which threatens health and causes many chronic complications including but not limited to heart ailments with which the life assured was

diagnosed. The relevant excerpt of the statement given by the nominee on the diabetic history of the life assured is reproduced below for the kind reference of the Hon’ble Ombudsman-

The complainant did not disclose true facts on his health condition and previous aliment of diabetes, which if would have been disclosed then we would not have issued any policy to the

complainant. Therefore the claim made by the complainant was denied by the opposite parties vide its claim denial letter dated 28.12.2019 the life assured suppressed about his true health condition.

The complainant did not disclose true facts on his health condition and previous aliment of diabetes (10 years), which if would have been disclosed then we would not have issued policy to the life assured. Further we have refunded the fund value of Rs.64107/- ( as on date of death) to the assignee HDFC LTD as the policy was assigned in the HDFC LTD by the life assured during his life time. Therefore this complaint as made by the complainant lacks merits and is liable to be dismissed.

3. I heard the complainant and the respondent Insurer. The complainant submitted repeatedly

that the all the details were submitted to the company without hiding any material information still the death claim was rejected for non disclosure of diabetes at the time of proposal .They further submitted that the proposal forms were made to sign blindly and was not aware of any details in the proposal form. If the company had asked or taken medicines the history of diabetes would have been exposed. The life assured died of heart attack and the claim was rejected for non disclosure of diabetes and requested the forum to direct the company to reconsider the claim since the treating doctor has confirmed that the death has taken place due to heart attack. The respondent Insurer submitted that in the proposal form, personal details of life assured question no 12, there is a question about diabetes and it was mentioned by the life assured as “not applicable”. In the hospital treatment certificate it was mentioned that the life assured had a history of diabetes. The complainant herself mentioned that the husband was

having diabetes but was under control. Company submitted that it is a case of non disclosure of facts hence repudiated.

4. It is evident from the medical reports submitted that the life assured was suffering from Diabetes and he ought to have disclosed at the time of talking the policy. That has not been done, it is confirmed that the insured has concealed facts with respect of his health and has

influenced the insurer on assessing the insurance cover. The submission of the complainant that the proposer was unaware of contents of the form is irrelevant as many papers are signed and was an educated person and advocate by profession. Material concealment has significant effect while issuing a policy and hence for the same reason the complaint is dismissed.



Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN


PROCEEDINGS OF


(UNDER RULE NO. 13 1(b) READ WITH RULE 14 OF







complainant

: Mr. K C VARKEY

KAKKANATTUPARAMBIL HOUSE,

KIZHILLAM P.O.,

PERUMBAVOOR,683 541

2. Policy Number

: 11399463


: Mr. K C VARKEY


: HDFC Standard Life Insurance Co.

Ltd.


: 24.08.2020


: Complaint regarding maturity claim


: --

8. Date of hearing : 08.10.2020


e) For the Complainant

: Mr. K C Varkey (online)

f) For the Insurer

: Mr. Vinay(online)

AWARD

This is a complaint filed under Rule 13 1(b) read along with Rule 14 of the Insurance

Ombudsman Rules, 2017. The complaint is Complaint regarding maturity claim. The

complainant, Mr. K C VARKEY is the policyholder.


The complainant stated that he had a unit linked pension plan in 2011 and remitted 2 lakh as

premiums. The policy matured in 2017. Since the complainant did not receive any maturity

amount on 2.12.2019 he went to the nearest respondent office to enquire about the policy and

it was conveyed that in 16.12.2010 an amount of Rs141914 was refunded . But the complainant

has not received any such amount. Complaint was given to grievance redressal but did not get

any response. The policy document is still with the complainant. The complainant is 80 year old

and requests the forum to refund his due 2 lakh.

2. The respondent insurer entered appearance and filed a self contained note. It is submitted

that the complainant had availed the Unit Linked Pension Plus Policy bearing No.11399463

from us on 22nd November 2007, and the policy was valid for 10 year and the complainant was

to pay premium for 10 years annually being Rs.2,00,000/-, as the policy was issued subject to

terms and conditions as mentioned therein. It stated that the complainant from second year

onwards sought for reducing the premium from Rs.2,00,000/- to Rs.20,000/- as the

complainant cited the reason that he could pay the premium. We accepted the request of the

complainant and reduced the premium to Rs.20000/- effective from 22nd November 2008

onwards. The copy of the letter written by the complainant seeking for reduction in the

premium sum from Rs.2,00,000/- to Rs.20000/- dated 13th October 2008 is provided for the

forums verification.

The complainant paid two premiums thereafter i.e. another sum of Rs.40,000/- was paid and

lastly on 22nd November 2010, the complainant defaulted in payment of the fourth installment

of the premium as a result the policy lapsed due non-payment of the premium although it had

attained paid-up status and as a result we paid the remaining fund value as on 22nd November

2010 to the complainant being a sum of Rs.141,914.52/- vide HDFC bank cheque bearing

No.770484 dated 16th December 2010, as the said cheque also got realized on 7th January

2011 from our HDFC Life’s account No. 00600350023230. The cheques were sent to the

complainant’s address on 18th December2010 vide DTDC courier with AWB No.M59413413.

The description of the payment made to the complainant is provided for reference.

The complainant after nine years wrote to the company in the month of November-2019,

stating that the complainant has not received the fund value till date as we wrote back to the

complainant on 2nd December 2019 stating that the fund of Rs.141,914.52/- was already paid

vide HDFC bank cheque bearing No.770484 dated 16th December 2010, as the said cheque also

got realized on 7th January 2011 from our HDFC Life’s account No. 00600350023230. The

relevant except of the letter dated 2nd December2019 is provided.

Upon receiving the complainant we enquired from the HDFC bank on the cheques being

realized in whose name, however the Bank replied to us stating that as per the document

retention policy the bank does not retain any documents beyond the period of eight years vide

their mail dated 30th November 2019. The relevant mail extract as received from the HDFC

bank is submitted.

Therefore it is submitted that the allegations made by the complainant is false, baseless and

untenable, as even otherwise this complaint is barred by time as the complainant cannot such

baseless claim after nine years, when the IRDA mandates the life insurer to maintain the

records for five years from the date of last transaction. Under these circumstances we humbly

submit that the complaint is devoid of merits and allegations made are false and baseless.

Therefore Hon’ble Ombudsman may be pleased to dismiss this complaint and thus rendered

justice.

3. I heard the complainant and the respondent Insurer. The complainant submitted that the

foreclosed amount paid by the company is not received and submitted three bank account

details, Bank of India,Federal Bank and State Bank of India to prove his claim. The complainant

further said that he was waiting till the maturity date and hence the delay in complaining. The

respondent Insurer submitted that as per the records of the company the amount is credited in

2011.Since it’s a time barred case getting the details is difficult.

4. Forum directed the company to submit the bank clearance details and a statement from the

bank HDFC was received on 14.10.2020 showing that the amount Rs141914 was credited to

Mr.K.C Varkey on 7.1.2011 in HDFC, Perumbavoor bank. Considering the facts of the case the

complaint is not tenable.



Sd/-

(POONAM BODRA)

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF RAJASTHAN

UNDER THE INSURANCE OMBUDSMAN RULES, 2017

OMBUDSMAN – MS. SANDHYA BALIGA

CASE OF FIROZ MOHD. V/S LIC OF INDIA

COMPLAINT REF: NO JPR- L-29-2021-0133

AWARD NO: IO/JPR/A/LI/ /2020-2021

1. Name & Address of the Complainant Sh. Firoz Mohd.

GPO-Indra Colony, Madhorajpura,

The- Phagi, Distt. Jaipur - 303006

2. Policy No:

Type of Policy

DOC/

Basic SA

478440163

Life

04.09.2017

Rs. 300000/-



Smt. Rahmat

Smt. Rahmat

4. Name of the insurer LIC of India ( DO-II, Jaipur )


6. Reason for repudiation Suppression of material facts regarding

health


8. Nature of complaint Less Death Claim received

9. Amount of Claim Rs. 300000/-

10. Date of Partial Settlement Rs. 36075/- on 13.07.2020

11. Amount of relief sought Rs. 263925/-


Rule no: of IOB rules

13 (1) (b)

13. Date of hearing/place 07.10.2020 / Video Conferencing through

GoToMeeting app


m) For the Complainant Sh. Firoz Mohd.

n) For the insurer Smt. Vanita Bhatia



17) Brief Facts of the Case:- :- Sh. Firoz ( herein after referred as complainant) had filed a

complaint against LIC of India (herein after referred to as respondent Insurance Company)

alleging less settlement of Death claim under policy no. 478440163 on the life of his deceased

mother Smt. Rahmat.


Complainant’s argument: The complainant submitted that his deceased mother had taken the

subject policy from the Sanganer branch of LIC of India. Her health was very

good. Suddenly his mother fell ill and was admitted in the SMS Hospital. On Doctor’s advice she

was taken to home, where she died. He submitted all claim paper to the Insurance Company for

settlement of Death Claim. The Insurance Company settled the death claim for Rs. 36075/- only

against Sum Assured of Rs. 300000/-. The Complainant had further represented his contention

to the GRO of the Insurance Company but did not get relief. Being aggrieved complainant

approached this forum for redressal of his grievance.

Insurer’s argument: - The respondent Insurance Company submitted in its SCN dated

22.09.2020 that above policy was issued on 04.09.2017 for SA Rs. 300000/- under plan 844-18-

18. DLA died on 23.01.2020. Death claim under the subject policy was repudiated due to

suppression of material facts regarding health by the life assured at inception of the policy. As

per BHT CR No. 1012000895395 of SMS Hospital Jaipur Adm. No. 10120010406 dated

19.01.2020, the DLA was F/C/O operated CVA Stroke 5 years ago. The DLA gave false answer to

Q. 11(D) (v) of proposal form and suppressed the material facts for insurance. As such the death

claim was repudiated. However as per Section 45 of Insurance Act, 1938, total premiums of Rs.

36075/- paid by the policyholder, was refunded to the nominee on 13.07.2020.

19) Reason for Registration of Complaint: Less settlement of death claim.


a) Complaint letter

b) Policy copy

c) Form VI A duly signed by the complainant.

d) SCN and form VIIA duly signed by the Insurance Company

21) Result of hearing with both parties (Observations and Conclusion):- The matter was heard

through video conferencing (GoToMeeting app) on 07.10.2020. The complainant submitted

that his insured mother had suffered a Stroke 7 years ago. The concerned agent of the

Insurance Company did not ask any thing about illness at the time of filling proposal form. As

such the fact was not disclosed in the proposal form. The Insurance Company reiterated that

Death claim under the subject policy was repudiated due to suppression of material facts

regarding health by the life assured at inception of the policy. As per BHT CR No.

1012000895395 of SMS Hospital Jaipur Adm. No. 10120010406 dated 19.01.2020, the DLA was

F/C/O operated CVA Stroke 5 years ago. The DLA gave false answer to Q. 11(D) (v) of proposal

form and suppressed the material facts for insurance. As such the death claim was repudiated.

However as per Section 45 of Insurance Act, 1938, total premiums of Rs. 36075/- paid by the

policyholder, was refunded to the nominee on 13.07.2020.

On perusal of the documents exhibited and oral submissions made during the hearing, I find

that as per BHT of SMS Hospital Jaipur Adm. No. 10120010406 dated 19. 01. 2020, the DLA was

F/C/O operated CVA Stroke 5 years ago. Even if the complainant’s contention that the insured

suffered a stroke seven years ago is considered, the fact of nondisclosure still remains. This

material fact regarding health was not disclosed by the

insured at the time of taking insurance policy. The Insurance Company repudiated the claim.

In view of above, I see no reason to interfere with the decision of the Insurance Company.

“Accordingly, the complaint is hereby dismissed.”

22) The attention of the Complainant and the insurer is hereby invited to the following

provisions of the Insurance Ombudsman Rules, 2017:

a. According to Rule 17(5) of Insurance Ombudsman Rules, 2017, a copy of the award shall be

sent to the complainant and the insurer named in the complaint.

Place: Jaipur SANDHYA BALIGA

Dated: 12.10.2020 (INSURANCE OMBUDSMAN)

AWARD

Taking into consideration the facts and circumstances of the case and

submissions made by both the parties, the complaint is hereby dismissed.

16(1)/17of THE INSURANCE OMBUDSMAN RULES, 2017 ...

Documents

Transcript of 16(1)/17of THE INSURANCE OMBUDSMAN RULES, 2017 ...