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Repudiation of Claim for Payor’s Benefit under Life Insurance Policy: While proposingfor Insurance, the Assured had not disclosed the fact of having taken treatment forHigh Blood Pressure and raised Cholesterol. The assured died within a year of takingthe Insurance Policy. Claim for Payor’s Benefit on death of the deceased Life Assuredwas repudiated by the Respondent on the basis of Statements given by the Assured’sWife and Brother both of whom were close relatives. Non-disclosure of the fact of HighBlood Pressure denied the opportunity to call for further Special Medical Report etc. Assuch, the facts being material for underwriting, the decision of the Respondent torepudiate the Claim was upheld.Ahmedabad Ombudsman CentreCase No. : 21-001-0161Mr. A J PatelVsLife Insurance Corporation of IndiaAward Dated : 26-10-2006Repudiation of Claim under Life Insurance Policy: While proposing for Insurance, theAssured had not disclosed the fact of having taken treatment for Chest Pain andDysnea on exertion on an off since 2 years, increased since 2 months, history ofDiabetes since 2 years and history of Hypertension since 6 months. These histories gobeyond the date of the Proposal. The assured died shortly after 2 years of taking theInsurance Policy. Besides on one occasion, the Deceased was admitted to a Hospitalshortly after he filled in the Proposal for Insurance but before the date of acceptance ofthe Risk. Claim on death of the deceased Life Assured was repudiated by theRespondent on the basis of Certificate of Hospital Treatment by reputed CardiacHospitals. Non disclosure of the fact of Hypertension/Diabetes/Chest pain denied theopportunity to call for further Special Medical Report etc. The case could have beensent over to the Higher Offices of the Insurer for decision. As such, the facts beingmaterial for underwriting, the decision of the Respondent to repudiate the Claim wasupheld.Ahmedabad Ombudsman CentreCase No. : 21-001-0189Ms. R J PandyaVsLife Insurance Corporation of IndiaAward Dated : 30-10-2006Repudiation of Claim for Accident Benefit under Life Insurance Policy: As per thecontention of the Complainant, the Assured fell down from a Scooter. Due to theinjuries, he died. The Respondent stated that the Cause of death as given in PostMortem Report is ‘Cardio Respiratory Failure due to pathology present in Heart. Thereis no mention of any major injury. Documents on record do not prove the Death asAccidental. The Newspaper report covering the event ascribed it to have been Heatinduced giddiness leading to the DLA falling down in an unconscious state. The Reportdoes not even mention of the Accident. As such, the decision of the Respondent torepudiate the Claim was upheld.Ahmedabad Ombudsman CentreCase No. : 21-001-0166Mr. R S ZalaVs

Life Insurance Corporation of IndiaAward Dated : 22-11-2006Repudiation of Claim under Life Insurance Policy: While proposing for Insurance, theAssured had not disclosed the fact of having taken treatment for ‘Major DepressionDisorder and Agoraphobia’ from a month prior to the date of Proposal. The treatmentcontinued till his death. The assured died within a month of taking the InsurancePolicy. Claim on death of the deceased Life Assured was repudiated by theRespondent on the basis of ESIC Certificate and Certificate by Employer confirming hisabsence supported by Medical Certificate by ESIC. Non disclosure of this denied theopportunity to call for further Special Reports etc. The case could have been sent overto the Higher Offices of the Insurer for decision. As such, the facts being material forunderwriting, the decision of the Respondent to repudiate the Claim was upheld.Ahmedabad Ombudsman CentreCase No. : 21-007-0123Sri V B GhamandeVsMax New York Life Insurance Co. Ltd.Award Dated : 22-11-2006Repudiation of Claim under Life Insurance Policy: The Insurance Policy was lying in alapsed state on the death of the Life Assured. The Complainant argued that theRespondent did not guide him properly with regard to required deposit to be made andother compliances for Renewal of his Policy. The responsibility to know the premiuminstalments and to pay them in time rests on the Life Assured. Since, the same was notdone, to claim the proceeds on a lapsed Policy, just alleging lack of adequate guidanceby the Insurer, cannot succeed. As such, the decision of the Respondent to repudiatethe subject Claim was upheld without any further relief.Ahmedabad Ombudsman CentreCase No. : 21-002-0180Smt. A B RuchananiVsLife Insurance Corporation of IndiaAward Dated : 27-11-2006Repudiation of Claim under Life Insurance Policy: While proposing for Insurance, theAssured had not disclosed the fact of taking treatment for ‘HCV related Cirrhosis ofLiver’ from nearly 4 months prior to the date of Proposal. The treatment continued tillhis death. The assured died within 7 months of taking the Insurance Policy. Claim ondeath of the deceased Life Assured was repudiated by the Respondent on the basis ofCertificate of Hospital Treatment from the Treating Doctor. Non disclosure of this factdenied the opportunity to call for further Special Reports etc. The case could havebeen sent over to the Higher Offices of the Insurer for decision. As such, the factsbeing material for underwriting, the decision of the Respondent to repudiate the Claimwas upheld.Ahmedabad Ombudsman CentreCase No. : 21-001-0168Mrs. B A ParmarVsLife Insurance Corporation of India

Award Dated : 27-11-2006Repudiation of Claim under Life Insurance Policy: While proposing for Insurance, theAssured had not disclosed the fact of taking treatment for ‘Chest pain (MI)’ and hadundergone Coronary Angiography only a year prior to the date of Proposal. Theassured died due to ‘Left Ventricular Dysfunction in a c/o Ischaemic Cardomyopathy,which proves the nexus between the undisclosed ailment and the cause of death. Claimon death of the deceased Life Assured was repudiated by the Respondent on the basisof Certificate of Hospital Treatment. Non disclosure of this fact denied the opportunityto call for further Special Reports etc. The case could have been sent over to theHigher Offices of the Insurer for decision. As such, the facts being material forunderwriting, the decision of the Respondent to repudiate the Claim was upheld.Ahmedabad Ombudsman CentreCase No. : 21-001-0198Smt. S S ShahVsLife Insurance Corporation of IndiaAward Dated : 7-12-2006Repudiation of Claim for Accident Benefit under Life Insurance Policy: The Assured felldown from the terrace of his house and died. Claim for Accident Benefit was repudiatedon the grounds that the Police Papers reflected the fact that the deceased wassuffering from Parkinson’s Disease which allegedly caused the death. As such, deathwas not an Accidental death. An observance of the Police FIR revealed that eventhough the Police Inspector wrote about the fact of the disease, he had not written thatthe disease contributed to the Accidental fall. The Post Mortem Report also confirmedthat the Death to be due to shock as a result of injuries sustained. In the absence ofany other acceptable indisputable evidence, the Respondent was directed to pay thefull Claim.Ahmedabad Ombudsman CentreCase No. : 21-001-0211Smt. Rinku K RajVsLife Insurance Corporation of IndiaAward Dated : 11-12-2006Repudiation of Claim under Life Insurance Policy: While filling up the forms forReviving a lapsed Life Insurance policy on the life of the deceased, the Assured hadnot mentioned the fact of his suffering from TB for two years before reviving the Policy.The above facts were confirmed by the treating Doctor, in the Certificate of HospitalTreatment, which also noted symptoms of Chest Pain, Cough, Fever and weight loss.The Insured was then put on anti-TB Drugs and severe Anaemia was treated with BloodTransfusion. CNS led to attacks of convulsions with as per the treating Doctor ‘couldhave been fatal’. The Assured died within four days of Revival due to the samedisease. Non disclosure of this material fact denied the Insurer an opportunity to callfor further Medical Reports in order to decide whether to accept the revival of thelapsed Insurance Policy. Thus the Revival was declared void and the decision of theRespondent to repudiate the Claim was upheld.Ahmedabad Ombudsman CentreCase No. : 21-001-0216

Sri. R N ShahVsLife Insurance Corporation of IndiaAward Dated : 18-12-2006Repudiation of Claim under Life Insurance Policy: While repudiating the Claim, theInsurer alleged that the DLA had given False Answers while taking the Policy forInsurance. During the course of Hearing, the Insurer admitted that there was noDocument to prove that the DLA ever contacted any Medical Practitioner prior to thedate of Proposal. The Inhouse Investigator too did not prove any suppression. In theabsence of any specific evidence of treatment prior to the date of Proposal, theRespondent was directed to pay the full Claim.Ahmedabad Ombudsman CentreCase No. : 21-004-0186Mr. N K VishraniVsICICI Prudential Life Insurance Co. Ltd.Award Dated : 18-12-2006Repudiation of Claim under Life Insurance Policy: While proposing for Insurance, theAssured had not disclosed the fact of having undergone tests like Haematology Report,Urine Examination Report, Chest X-Ray Report, Echo (Color Doppler) Report andSpine X-Ray Report only 7 days prior to the date of Proposal under the advice of aCardiologist. The nature of these Tests clearly show that they have not been done as amatter of routine. The assured died within 5 months of taking the Insurance Policy.Claim on death of the deceased Life Assured was repudiated by the Respondent. Thenon-disclosure had a direct impact on the Underwriting decision. As such, the factsbeing material for underwriting, the decision of the Respondent to repudiate the Claimwas upheld.Ahmedabad Ombudsman CentreCase No. : 21-001-0201Mr. K H PatelVsLife Insurance Corporation of IndiaAward Dated : 28-12-2006Repudiation of Claim under Life Insurance Policy: While proposing for Insurance, theInsured had not informed that fact of her having undergone an AbdominalHysterectomy, three years back. Claim on death of the deceased Life Assured wasrepudiated by the Respondent on the basis of the Certificate of Hospital Treatment.Non disclosure of this fact denied the opportunity to call for further Special Reportsetc. Misstatement in this regard sniped Utmost Good Faith which forms the cornerstoneof Insurance Contract. As such, the decision of the Respondent to repudiate the Claimwas upheld.Ahmedabad Ombudsman CentreCase No. : 21-001-0178Mr. Suresh BansalVsLife Insurance Corporation of IndiaAward Dated : 17-1-2007

The Complainant’s husband held a Jeevan Suraksha Policy with endowment option. Onhis death, payment of annuity was done as per Option F-Life Annuity with Return ofCapital Sum. The Policy Document stated that “Annuity Rates for the various optionswill be quoted on application”. It was observed that from the Monthly Pensions havebeen calculated correctly as per the Insurer’s internal instructions by which theprevailing immediate annuity as at the date of death have to be applied, based on theage of spouse. Hence, no relief was warranted for the Complainant.Ahmedabad Ombudsman CentreCase No. : 21-001-0233Sri C R PatelVsLife Insurance Corporation of IndiaAward Dated : 22-1-2007Repudiation of Claim under Life Insurance Policy: While proposing for Insurance, theAssured had not disclosed the fact of having undergone treatment for Sinusitis for thelast one year, as evidenced from the Certificate of the Treating Doctor. The assureddied within 22 days of taking the Insurance Policy. Claim on death of the deceased LifeAssured was repudiated by the Respondent. Since, the non-disclosure sniped UtmostGood Faith, which formed the cornerstone of Insurance Contract, the decision torepudiate the Claim was upheld.Ahmedabad Ombudsman CentreCase No. : 21-001-0260Mr. K S MakadiyaVsLife Insurance Corporation of IndiaAward Dated : 23-1-2007Repudiation of Claim under Life Insurance Policy: While proposing for Insurance, theInsured had not informed that fact of his having had a history of pain in Chest andDyspnoea as also Cough and blood in Sputum and Asthma for which he had beenundergoing treatment. Claim on death of the deceased Life Assured was repudiated bythe Respondent on the basis of the Certificate of Treatment. Non disclosure of this factdenied the opportunity to call for further Special Reports etc. Misstatement in thisregard sniped Utmost Good Faith which forms the cornerstone of Insurance Contract.As such, the decision of the Respondent to repudiate the Claim was upheld.Ahmedabad Ombudsman CentreCase No. : 21-001-0276Mr. N M ParmarVsLife Insurance Corporation of IndiaAward Dated : 13-2-2007Repudiation of Claim under Life Insurance Policy: As per records the Deceased ignitedherself by pouring Kerosene. The Uncle-in-law of the DLA took her to a burnt state fortreatment but when the body arrived, she was declared dead. The Post-Mortem andFSL Report both confirmed that the death took place due to burn injuries which tookplace in the residence of the DLA. The risk cover under the Policy commenced on 20-6-2003. Death took place on 26-10-2005. As such, the decision of the Insurer to

epudiate the liability under the Policy and to refund the premiums paid without interestas per conditions of the Policy Clause 4B was upheld.Ahmedabad Ombudsman CentreCase No. : 21-001-0250Mr. J M ParmarVsLife Insurance Corporation of IndiaAward Dated : 14-2-2007Repudiation of Claim under Life Insurance Policy by invoking Suicide Clause: It wasobserved that the Deceased died due to falling into a well on 16-7-2005 due tounknown reasons. Post Mortem Report opined cause of death as “Asphyxia due todrowning”. The Date of Commencement of risk under the Policy was 28-5-2005. Claimwas repudiated since the Suicide occurred within one year from the commencement ofrisk. The Respondent could not prove any document which stated the cause of Deathas Suicide. Since there was no direct or concrete hard evidence to prove the cause ofDeath, repudiation was set aside and the Respondent was directed to settle the Claim.Ahmedabad Ombudsman CentreCase No. : 21-002-0264Mrs. M P JainVsSBI Life Insurance Co. Ltd.Award Dated : 15-2-2007Repudiation of Claim under Life Insurance Policy: While filling up the Proposal forInsurance, the Assured had not mentioned the fact that he was hospitalised forIschaemic Heart Disease, High Blood Pressure and Diabetes three years prior to fillingup the Good Health Declaration in order to take the Insurance. The Assured died dueto a sudden Heart Attack, which had a direct nexus with the mis-statement within 25days of taking the Insurance Policy. The non-disclosure being established to have beenmaterial, the decision of the Respondent to repudiate the Claim was upheld.Ahmedabad Ombudsman CentreCase No. : 21-012-0270Smt. P R BatungeVsMetLife Insurance Co. Ltd.Award Dated : 28-2-2007Repudiation of Death Claim: The Death Claim was repudiated on the ground ofmisstatement of Educational Qualifications and Employment of the Deceased. Whilefilling the Proposal Form, the Life Assured had mentioned that he had passed B.Com.and that he was working with Khodiyar Music with nature of duties as ‘Administration &Music’. During the course of submissions and in the Hearing too, the widow of theDeceased confirmed that the deceased had studied upto 9 th Standard only. Again itwas found that the deceased was not in full time employment. He was only a freelancerrather than a whole time employee and would play Band and be paid on per programmebasis. The contradictions being proved, the alleged misstatement got established it

sniped at Utmost Good Faith that forms the cornerstone of insurance contract. As such,repudiation was upheld with no relief to the Complainant.Ahmedabad Ombudsman CentreCase No. : 21-002-0228Mr. M B SurekaVsSBI Life Insurance Co. Ltd.Award Dated: 12-3-2007Repudiation of Claim under Life Insurance Policy: Claim was repudiated since theInsured had died within 45 days from the date of Commencement of Risk. TheComplainant submitted that the Forms etc. were submitted approximately two monthsbefore the date of Commencement of Risk. However, the Certificate of Insuranceissued to the Insured clarifies that the date of commencement of risk is the day onwhich the Premium is debited. It was observed that the Assured died 40 days after therisk commencement date. As such, the decision to repudiate the Claim was upheld.Ahmedabad Ombudsman CentreCase No. : 21-001-0303Sri. R G ChamarVsLife Insurance Corporation of IndiaAward Dated : 12-3-2007Repudiation of Claim under Life Insurance Policy: While filling up the Proposal forInsurance, the Assured had by giving a Self Declaration of Age stated that his age atentry is 39 years. The Assured died within 13 months from the date of proposal. Onenquiry, it was found that the DLA’s Son was aged 28 years as per the age recorded inthe School Certificate. Again the DLA’s wife’s age as recorded in the Identity Card ofElection Commissioner of India comes to 56 years. The mis-statement of age beingestablished to have been material, the decision of the Respondent to repudiate theClaim was upheld.Bhopal Ombudsman CentreCase No.: LI-1025-21/09-07/INDSmt. Basanti Bai GuptaVsLife Insurance Corporation of IndiaAward Dated : 17.11.2006Smt. Basanti Bai Gupta, resident of Indore (M.P.) (hereinafter called Complainant) isthe wife of late Shri Jagdish Chandra Gupta, Deceased Life Assured (in short DLA).The DLA took a life insurance policy numbered 344289934 from LIC of India, DO:Indore, BO-5, Indore (hereinafter called Respondent) on 28.12.2004 for Sum Assuredof 1,00,000/- under Table/Term: 149-20. The DLA died on 12-09-2005 due to heartattack. The complainant has complained that she had preferred death claim with theRespondent but the same was repudiated on the grounds of understatement of age byDLA at the time of taking the policy in question. The claimant preferred a complaint tothis Office.

DLA died on 26.01.2003 due to DM Chronic Renal Failure Then, the death claim waspreferred by Complainant with the Respondent, which was repudiated by theRespondent on the grounds of suppression of material facts regarding health of DLA atthe time of revival. Then the complainant had referred the case to Respondent’s ClaimsReview Committee for reconsideration which was also upheld by them on 06.06.2006.The claimant preferred a complaint to this Office.Observations of Ombudsman: I have gone through the materials on records andsubmissions made during hearing and summaries my observations as follows:There is no dispute that the Policy No. 351488035 was issued to DLA by theRespondent on 28-08-1999; the same was revived on 15-12-2001 and death of DLAoccurred on 26-01-2003.During hearing, the complainant informed that the DLA was not suffering from anydiseases and was in good health at the time of revival of the policy in question.During hearing, the Respondent contended that The Case History Sheet of BhopalMemorial Hospital also reveals the History of Hypertension since 1995, DiabetesMellitus since 1995,CAD since 1999 etc. Dr. Quasim Ali Anjum has in claim form ‘ B ‘certified the primary cause of death as “ Cardio-respiratory failures “ and secondarycause of death is as “Diabetes c Chronic Renal Failure” However the history ofaforesaid diseases/ailments were not mentioned by the DLA in the DGH dated04.12.2001 submitted for revival of the policy. The DLA was diagnosed for aforesaiddiseases/ailments and hence the claim was repudiated due to concealment of materialfacts regarding health of DLA. Had the DLA’s ill health and treatment details beenbrought to the knowledge of the Respondent during revival in DGH submitted by theDLA, the underwriting decision of the Respondent would have been different.On scrutiny, it is observed from The Claim form B, DGH, ECG Report of NiramayHospital and Ayushman Hospital dated 06.01.2001and 06.12.2000 respectively, HistorySheet of Bhopal Memorial Hospital, Angiography Report dated 14.02.2001 of HinjujaHospital, letter dated 10.08.2005 of Dr.Rajeev Madan. that it was a known case ofhypertension since 1995, Diabetes Mellitus since1995 and coronary artery diseasesince June 1999.It is further observed from Claim form B issued by Dr. Quasim Ali Anjum 133,M.P.Nagar- Zone-II, BHOPAL has in claim form ‘ B ‘ certified the primary cause ofdeath as “ Cardio-respiratory failures “ and secondary cause of death is as “Diabetes cChronic Renal Failure” whereas in the Declaration of Good Health (DGH) report signedby DLA on 15-12-2001 during revival shows that the he had never suffered from anyailment whatsoever in the past and that he was absolutely keeping normal health.Thus, from the foregoing facts it is clear that there is a direct nexus between the causeof death and the ailments suffered by DLA. Hence, it is clear that the DLA intentionallysuppressed the material facts regarding health to the Respondent at the time ofreviving the policy in question.Insurance is a contract of Utmost Good Faith where both parties are required todisclose all the material facts. No party can be allowed to gain any undue advantage bysuppressing any fact. In the instant case, there are sufficient evidential proofs to showthat the DLA was already suffering from serious ailments but suppressed the same inthe DGH report at the time of revival. Thus, the DLA has misled the Respondent by notproviding vital information regarding his health at the time of revival and hence theRespondent was not able to take proper underwriting decision. Had the facts beenbrought to the knowledge of the Respondent, its underwriting decision would have beendifferent.

In view of the above, the decision taken by the Respondent is just and fair hence doesnot require any interference.Bhopal Ombudsman CentreCase No.: LI-1050-21/09-07/BPLSmt. Gangotri Bai DadoreVsLife Insurance Corporation of IndiaAward Dated : 21.11.2006Smt. Gangotri Bai Dadore, resident of Amla Distt.: Betul (M.P.) [hereinafter calledComplainant] is the wife of late Shri Deep Chand Dadore, Deceased Life Assured [inshort DLA]. DLA took a life insurance policy numbered 372079113 from LIC of India,DO: Bhopal, BO Betul [hereinafter called Respondent]. The Policy commenced on15.01.1999 lapsed due to non-payment of premiums. The policy was revived by DLA on29.04.2003 by paying the arrears of premiums. The DLA died on 27.02.2005 due tostomach pain. The death claim was preferred by Complainant with the Respondent,which was repudiated by the Respondent on the grounds of suppression of materialfacts regarding health of DLA at the time of revival. The complainant had referred thecase to Respondent’s Claims Review Committee for reconsideration which was alsoupheld by them on 06.06.2006. Aggrieved from the repudiation action of Respondent,the Complainant has lodged a complaint with this Office seeking directions toRespondent to settle the claim amount.Observations of Ombudsman: I have gone through the materials on records andsubmissions made during hearing and summaries my observations as follows:There is no dispute that the Policy No. 372079113 was issued to DLA by theRespondent on 15.01.1999; the same was revived on 29.04.2003 and death of DLAoccurred on 27.02.2005.During hearing, the complainant informed that the DLA was not suffering from anydisease and was in good health at the time of revival of the policy in question.During hearing, the Respondent contended that there is sufficient evidences confirmingthat the DLA was diagnosed for cirrhosis of liver and was a known case of hepatitis ‘B’for last 4 years and was taking lamirudin tablet for the same. However, the history ofaforesaid diseases/ailments was not been mentioned by the DLA in the DGH dated29.03.2003 submitted for revival of the policy. The DLA was diagnosed for aforesaiddiseases/ailments and hence the claim was repudiated due to concealment of materialfacts regarding health of DLA. Had the DLA’s ill health and treatment details beenbrought to the knowledge of the Respondent during revival in DGH submitted by theDLA, the underwriting decision of the Respondent would have been different.On scrutiny, it is observed from Claim form ‘B’, Dr. Sudhir Gupta, MD,DM, Govt.Medical College, Nagpur has under question no-5(a) in claim Form B , stated thatpatient was chronic alcoholic and alcoholism was the cause for cirrhosis. To questionno- 4(a), he stated that the primary cause of death as CRA and secondary cause asIDDM c HbAg related cirrholis of liver c Ascitis PHT c Hepatorenal Syndrome.It is further observed from Claim form B issued by Dr. Sudhir Gupta has in claim form ‘B ‘ certified the primary cause of death as “ Cardio-respiratory failures “ and secondarycause of death is as “Diabetes c Chronic Renal Failure” whereas in the Declaration ofGood Health (DGH) report signed by DLA on 15-12-2001 during revival shows that the

he had never suffered from any ailment whatsoever in the past and that he wasabsolutely keeping normal health, hence the contention of Complainant is not tenable.Thus, from the foregoing facts it is clear that there is a direct nexus between the causeof death and the ailments suffered by DLA. Hence, it is clear that the DLA intentionallysuppressed the material facts regarding health to the Respondent at the time ofreviving the policy in question.Insurance is a contract of Utmost Good Faith where both parties are required todisclose all the material facts. No party can be allowed to gain any undue advantage bysuppressing any fact. In the instant case, there are sufficient evidential proofs to showthat the DLA was already suffering from serious ailments but suppressed the same inthe DGH report at the time of revival. Thus, the DLA has misled the Respondent by notproviding vital information regarding his health at the time of revival and hence theRespondent was not able to take proper underwriting decision. Had the facts beenbrought to the knowledge of the Respondent, its underwriting decision would have beendifferent.In view of the circumstances stated above, I am of the considered opinion that thedecision taken by the Respondent is just and fair hence does not require anyinterference.Bhopal Ombudsman CentreCase No.: LI-1026-21/09-07/RPRSmt. Sharda Devi GuptaVsLife Insurance Corporation of IndiaAward Dated : 26.12.2006Smt. Sharda Devi Gupta, resident of Jamnapali Distt, Korba [hereinafter calledComplainant] is the wife of Late Shri Gouri Shankar Gupta, Deceased Life Assured (inshort DLA). The DLA had a life insurance policy number 382837709 taken from LIC ofIndia, DO: Raipur, BO-1, Korba [hereinafter called Respondent]. The Policycommenced on 28.03.2003 under Table/Term: 151-05 (3) for Sum Assured of Rs. 5,00,000/- The DLA expired on 13.12.2003 due to Diabetes Mellitus IAD-A with MIA withHeart Failure. The death claim was preferred by the Complainant with the Respondentbut the same was repudiated on the grounds of suppression of material facts regardinghealth of DLA at the time of taking policy. Aggrieved from the repudiation action ofRespondent, the Complainant has lodged a complaint with this Office seekingdirections to Respondent to settle the claim amount under the policy.Observations of Ombudsman : I have gone through the materials on records andsubmissions made during hearing and summarize my observations as follows:There is no dispute that the policy number 382837709 was issued to DLA by theRespondent on 28.03.2003 and death of DLA occurred on 13.12.2003.During hearing the complainant stated that the DLA was an employee of NTPC Korbataken voluntary retirement from service before more than 2 ½ years and further addedthat the leaves were taken on medical ground as DLA was transferred to Rewa wherehe did not want to join there and was trying to cancel his transfer.During hearing, the Respondent contended that there are sufficient evidencesconfirming that the DLA was a known case of DM with HTN prior to taking the policy.However, the history of aforesaid diseases/ailments was not been mentioned by theDLA in the proposal form dated 17.02.2003 submitted for above policy. The DLA wasdiagnosed for aforesaid diseases/ailments and hence the claim was repudiated due to

concealment of material facts regarding health of DLA. Had the DLA’s ill health andtreatment details been brought to the knowledge of the Respondent in the proposalform submitted by the DLA, the underwriting decision of the Respondent would havebeen different.It is observed from the Medical certificate dated 10.06.2002 and 10.08.2002 issued bythe Medical Officer of NTPC Hospital Korba (M.P.) that the DLA was suffering from DMc Nephrotities & DM c HT c IHD with CRF and the same is also confirmed from theOPD Ticket issued by the NTPC Hospital Korba. Hence the contention of theComplainant that the leaves are taken on medical ground for other purpose is nottenable.It is also observed from Claim forms B & B1 issued by the NTPC Hospital Korba whoattended the DLA during his last illness that the primary cause of death is DiabetesMellitus c IHD with the history of disease of 15 years. This clearly shows that DLA wasalready suffering from Diabetes Mellitus and Hypertension but intentionally suppressedin the Proposal forms under Policy in question.Insurance is a contract of Utmost Good Faith where both parties are required todisclose all the material facts. No party can be allowed to gain any undue advantage bysuppressing any fact. In the present case, there are sufficient evidential proofs to showthat the DLA was already suffering from serious ailments but suppressed in theProposal form. Had the same been brought to the knowledge of the Respondent, theunderwriting decision would have been different.In view of the above, the decision taken by the Respondent is just and fair hence doesnot require any interference.The complaint is dismissed without any relief.Bhopal Ombudsman CentreCase No.: LI-974-21/08-07/RPRShri Dilip Kumar ShrivastavVsLife Insurance Corporation of IndiaAward Dated : 26.12.2006Shri Dilip Kumar Shrivastav, resident of Keshkal Distt.: Bastar (M.P.) [hereinaftercalled Complainant] is the husband of late Smt. Shakuntala Shrivatav, Deceased LifeAssured [in short DLA]. The DLA took a life insurance policy numbered 382886548under Table/Term 14-5 for sum assured of Rs 1,00,000/- from LIC of India, DO: Raipur,BO Jagdalpur [hereinafter called Respondent]. The Policy commenced on 28.12.2002.The DLA died on 28.11.2003 due to Rheumatic Heart Disease. The death claim waspreferred by Complainant with the Respondent which was repudiated by theRespondent on the grounds of suppression of material facts regarding health of DLA atthe time of taking the policy. The complainant had referred the case to Respondent’sClaims Review Committee for reconsideration which was also upheld by them on06.06.2006. Aggrieved from the repudiation action of Respondent, the Complainant haslodged a complaint with this Office seeking directions to the Respondent to settle theclaim amount.Observations of Ombudsman : I have gone through the materials on records andsubmissions made during hearing and my observations are as follows:There is no dispute that the Policy No. 382886548 was issued to DLA by theRespondent on 28.12.2002 and death of DLA occurred on 28.11.2003.During hearing, the complainant informed that the DLA was not suffering from anydisease and was in good health at the time of taking the policy in question. The

Complainant further informed that the DLA was admitted for second delivery in theChristian Hospital, Dhamtari in the year 1991 and she was in good health afterdischarge from the hospital till 4 th January 2003.During hearing, the Respondent replied that there is sufficient evidence confirming thatthe DLA was suffering from Rheumatic Heart Disease with other ailments since 1991which was not disclosed at the time of taking the policy no. 383886548 on 25.12.2002.This information was very much material to the Respondent for deciding the case.Considering the above facts the Respondent repudiate the claim with the reason“suppression of material facts”.On scrutiny, it is observed from the certificate issued by the Dr. S.K.Chatterjee Medicalsuperintendent of Dhamtary Christian Hospital, Dhamtari (C.G.) dated 16.05.2005 thatthe DLA was taking treatment from DCH DMT for sever MR Mild to Moderate MS,Chronic Rheumatic Heart Disease sickle cell D/s irregularly since 1991.It is also seen from the copy of ECHO CARDIOGRAM Report dated 02.05.2003 fromthe Cardiologist, Dhamtari Christian Hospital, Dhamtari that the clinical diagnosis isRHD with MS + MR.Thus, from the foregoing facts it is clear that the DLA has intentionally suppressed thematerial facts regarding her health to the Respondent at the time of taking the policy inquestion.Insurance is a contract of Utmost Good Faith where both parties are required todisclose all the material facts. No party can be allowed to gain any undue advantage bysuppressing any fact. In the instant case, there is a sufficient evidential proof to showthat the DLA was already suffering from serious ailments but suppressed the same inthe proposal form at the time of taking the policy. Thus, the DLA has misled theRespondent by not providing vital information regarding her health at the time ofproposal and hence the Respondent was not able to take proper underwriting decision.Had the facts been brought to the knowledge of the Respondent, its underwritingdecision would have been different.In view of the circumstances stated above, I am of the considered opinion that thedecision taken by the Respondent is just and fair hence does not require anyinterference.The complaint is dismissed without any relief.Bhopal Ombudsman CentreCase No.: LI-1066-21/10-07/INDSmt.Ratan Bai BaroniaVsLife Insurance Corporation of India, DO: IndoreAward Dated : 28.12.2006Smt. Ratan Bai Baronia, resident of Indore [hereinafter called Complainant] is the wifeof Late Shri Gopal Baronia, Deceased Life Assured (in short DLA). The DLA had a lifeinsurance policy number 340361465 taken from LIC of India, DO: Indore, BO-1, Indore[hereinafter called Respondent]. The Policy commenced on 11.02.2003 underTable/Term: 154-12 for Sum Assured of 50,000/- The DLA expired on 18.09.2005 dueto heart attack. The death claim was preferred by the Complainant with the Respondentbut the same was repudiated on the grounds of suppression of material facts regardinghealth of DLA at the time of taking policy. Aggrieved from the repudiation action ofRespondent, the Complainant has lodged a complaint with this Office seekingdirections to Respondent to settle the claim amount under the policy.

The complaint was registered and necessary forms were issued to both the parties.Replies were received from both the parties.The Respondent vide its self-contained note received by this office on 18.10.2006replied that DLA having history as known case of Coronary Artery Disease – Old Anterolateral MI and had history of appendectomy in 1977 at the time of proposing forinsurance under the policy. However, DLA had not disclosed his illness in the proposalforms submitted for insurance and has stated his state of health was “GOOD”. Had thehistory of Coronary Artery Disease – Old Antero lateral MI been disclosed at the timeof proposing for insurance, decision for acceptance of the case would have beenaffected. Hence, the claim under the policy was repudiated due to non-disclosure ofmaterial facts.The policy in question was proposed on 08.02.2003 is after all these incidentswherever he did not mentioned any thing about his all these past illness. Consideringall these facts LIC repudiated the claim for the reason “Suppression of material facts”on 07.04.2006. Further the case was referred to the Claim Review Committee at LICZonal Office Bhopal. The ZO CRC in its meeting held on 26.07.2006 upheld the DOdecision of repudiation on 01-09-2006.Observations of Ombudsman : I have gone through the materials on records andsubmissions made during hearing and summaries my observations as follows:There is no dispute that the policy number 340361465 was issued to DLA by theRespondent on 11.02.2003 and death of DLA occurred on 18-09.2005 due to heartattack.During hearing, the complainant informed that the DLA was not suffering from anydisease and was in good health at the time of taking the policy in question. TheComplainant further stated that the DLA was an employee as Watchman of FoodCorporation of India, Indore and taken voluntary retirement before retirement date fromservice as his office was situated on third floor due to stone in kidney.The Complainant also added that the DLA was having total four policies bearing nos.341193139, 341196468, 341195974 and 342361465 and out of these four policies shehas received the death claim amount about Rs. 1.40 lacs under three policies exceptthis policy no 340361465.The Respondent contented during hearing that the DLA was having a history, as knowncase of Coronary Artery Disease – Old Antero lateral MI and had history ofappendectomy in 1977 at the time of proposing for insurance under the policy.However, DLA had not disclosed his illness in the proposal forms submitted forinsurance and has stated his state of health was “GOOD”. Had the history of CoronaryArtery Disease – Old Antero lateral MI been disclosed at the time of proposing forinsurance, decision for acceptance of the case would have been affected. Hence, theclaim under the policy was repudiated due to non-disclosure of material facts.It is observed from records that DLA was an employee of FCI and was posted asChokidar. It is also observed from the records of CHL-Apollo Hospital Indore dated 16-06-2005 shows that the DLA was a known case of Caronary Artery Disease – OldAntero lateral MI.It is also clear from the history sheet of Charak Hospital of Indore dated 18.07.2003that DLA was already suffering from Coronary Artery Disease – Old Antero lateral MIsince one year which appears the date prior to the date of proposal for insurance butintentionally suppressed in the Proposal forms under Policy in question.Insurance is a contract of Utmost Good Faith where both parties are required todisclose all the material facts. No party can be allowed to gain any undue advantage by

suppressing any fact. In the present case, there are sufficient evidential proofs to showthat the DLA was already suffering from serious ailments but suppressed in theProposal form. Had the same been brought to the knowledge of the Respondent, theunderwriting decision would have been different.In view of the above, the decision taken by the Respondent is just and fair hence doesnot require any interference.The complaint is dismissed without any relief.Bhopal Ombudsman CentreCase No.: LI-1088-21/10-07/INDShri Chindhu Namdeo MahajanVsLife Insurance Corporation of IndiaAward Dated : 29.12.2006Shri Chindhu Namdeo Mahajan, resident of Deopur Distt.: Dhuliya (M.S.) [hereinaftercalled Complainant] is the father of late Smt. Shobha Mahajan, Deceased Life Assured[in short DLA]. The DLA took a life insurance policy numbered 344255882 from LIC ofIndia, DO: Indore, BO Burhanpur [hereinafter called Respondent]. The Policycommenced on 08.03.2005. The DLA died on 25.09.2005 due to high fever. The deathclaim was preferred by Complainant with the Respondent, which was repudiated by theRespondent on the grounds of suppression of material facts regarding health of DLA atthe time taking the policy. The complainant had referred the case to Respondent’sClaims Review Committee for reconsideration which was also upheld by them on04.10.2006. Aggrieved from the repudiation action of Respondent, the Complainant haslodged a complaint with this Office seeking directions to Respondent to settle the claimamount.The complaint was registered & necessary forms were issued to both the parties.Replies were received from both the parties.The Respondent vide its self-contained note received by this office on 15.11.2006replied that the Policy had run for 6 months & 17 days from the date of commencementof policy. The DLA was sick having complaint of severe anemia c fever c severe weightloss etc. before the date of proposal. The Section 45 also is in L.I.C’s favour. TheRespondent further added that it is very clear from the leave records and certificates ofSickness as well as the Hospital record of being HIV +ve.Observations of Ombudsman : I have gone through the materials on records andsubmissions made during hearing and summaries my observations as follows:There is no dispute that the Policy No. 344255882 was issued to DLA by theRespondent on 08.03.2005 and death of DLA occurred on 25.09.2005.During hearing, the complainant informed that the DLA was not suffering from anydisease and was in good health at the time of taking the policy in question.On scrutiny, it is observed from Claim form ‘B’, Dr. Sudhir Gupta, MD,DM, Govt.Medical College, Nagpur has under question no-5(a) in claim Form B , stated thatpatient was chronic alcoholic and alcoholism was the cause for cirrhosis. To questionno- 4(a), he stated that the primary cause of death as CRA and secondary cause asIDDM c HbAg related cirrholis of liver c Ascitis PHT c Hepatorenal Syndrome.It is further observed from Claim form B issued by Dr. Sudhir Gupta has in claim form ‘B ‘ certified the primary cause of death as “ Cardio-respiratory failures “ and secondarycause of death is as “Diabetes c Chronic Renal Failure” whereas in the Declaration ofGood Health (DGH) report signed by DLA on 15-12-2001 during revival shows that the

he had never suffered from any ailment whatsoever in the past and that he wasabsolutely keeping normal health, hence the contention of Complainant is not tenable.Thus, from the foregoing facts it is clear that there is a direct nexus between the causeof death and the ailments suffered by DLA. Hence, it is clear that the DLA intentionallysuppressed the material facts regarding health to the Respondent at the time ofreviving the policy in question.Insurance is a contract of Utmost Good Faith where both parties are required todisclose all the material facts. No party can be allowed to gain any undue advantage bysuppressing any fact. In the instant case, there are sufficient evidential proofs to showthat the DLA was already suffering from serious ailments but suppressed the same inthe proposal form at the time of taking the policy. Thus, the DLA has misled theRespondent by not providing vital information regarding his health at the time ofproposal and hence the Respondent was not able to take proper underwriting decision.Had the facts been brought to the knowledge of the Respondent, its underwritingdecision would have been different.In view of the circumstances stated above, I am of the considered opinion that thedecision taken by the Respondent is just and fair hence does not require anyinterference.The complaint is dismissed without any relief.Bhopal Ombudsman CentreCase No.: LI-1129-21/11-07/INDSmt.Prabha Devi ChhajedVsLife Insurance Corporation of IndiaAward Dated : 18.01.2007Smt.Prabha Devi Chhajed, resident of Neemuch [hereinafter called Complainant] is thewife of Late Shri Tejpal Chhajed, Deceased Life Assured (in short DLA). The DLA hada life insurance policy number 344485756 taken from LIC of India, DO: Indore, BO-Neemuch [hereinafter called Respondent]. The Policy commenced on 02.02.2005 underTable/Term: 149-15 for Sum Assured of 1,00,000/- The DLA expired on 03.06.2005 dueto tumor in Alimentary canal. The death claim was preferred by the Complainant withthe Respondent but the same was repudiated on the grounds of suppression ofmaterial facts regarding health of DLA at the time of taking policy. Aggrieved from therepudiation action of Respondent, the Complainant has lodged a complaint with thisOffice seeking directions to Respondent to settle the claim amount under the policy.The Respondent vide its self-contained note received by this office on 26 thDecember,2006 replied that DLA was suffering from Tumor in Alimentary Canal at thetime of proposing for insurance under the policy. However, DLA had not disclosed hisillness in the proposal forms submitted for insurance and has stated his state of healthwas “GOOD”. Had the history of Tumor in Alimentary Canal been disclosed at the timeof proposing for insurance, decision for acceptance of the case would have beenaffected. Hence, the claim under the policy was repudiated due to non-disclosure ofmaterial facts.The proposal of the policy in question was completed on 03.03.2005 and DLA wassuffering from tumor in Alimentary Canal from 01.03.2005 to 03.06.2005 as per form no3802 submitted by the Dr.Nand Kishore Mangal Neemuch who treated the deceasedassured during his life time. The DLA did not mention any thing about his past illness.Considering all these facts LIC repudiated the claim for the reason “Suppression of

material facts” on 31.03.2006. Further the case was referred to the Claim ReviewCommittee at LIC Zonal Office Bhopal. The ZO CRC in its meeting upheld the DOdecision of repudiation on 01-09-2006.Observations of Ombudsman:I have gone through the materials on records and submissions made during hearingand summaries my observations as follows:There is no dispute that the policy number 344485756 was issued to DLA by theRespondent on 02.02.205 and death of DLA occurred on 03.06.2005 due to tumor inAlimentary canal.It is observed from the record that the Complainant has submitted the forms P-2 and P-3 duly filled up but without her signature. Further the Complainant was absent on thedate of hearing in spite of proper service, which shows that the Complainant is notinterested in resolving his grievances. In view of the above, the complaint is dismissedwithout any relief.Bhopal Ombudsman CentreCase No.: LI-1133-21/12-07/BPLSmt. Kamini PahareVsLife Insurance Corporation of IndiaAward Dated : 19.01.2007Smt. Kamini Pahare, resident of Gram Nimsadiya Distt.: Hoshangabad (M.P.)[hereinafter called Complainant] is the wife of late Shri Dinesh Chand Pahare,Deceased Life Assured [in short DLA]. The DLA took a life insurance policy numbered351860961 from LIC of India, DO: Bhopal, BO Hoshangabad [hereinafter calledRespondent]. The Policy commenced on 10.03.2002 lapsed due to non-payment ofpremiums. The policy was revived by DLA on 24.06.2005 by paying the arrears ofpremiums. The DLA died on 21.07.2005 due to Complicated Malaria c ARDS c ARF.The death claim was preferred by Complainant with the Respondent, which wasrepudiated by the Respondent on the grounds of suppression of material factsregarding health of DLA at the time of revival. The complainant had referred the caseto Respondent’s Claims Review Committee for reconsideration which was also upheldby them on 01.11.2006. Aggrieved by the repudiation action of Respondent, theComplainant has lodged a complaint with this Office seeking directions to Respondentto settle the claim amount.The complaint was registered and necessary forms were issued to both the parties.Replies were received from both the parties.The Respondent vide its self-contained note dated 12.012.2006 replied that the Policyhad run for 3 years 4 month and 11 days from date of commencement (DOC) and onlyfor 27 days from the date of revival. The DOC under the policy is 10.03.2002 and dueto non payment of premiums the policy got lapsed since quarterly premium due12/2004. The same was got revived on 24.06.2005 by paying the arrears of premiumsand by submitting the Declaration of Good Health (DGH). In the DGH, the question no7 viz “Have you suffered from any diseases requiring treatment for more than 7 days?”has been answered as “NO”. However, the employer has confirmed in claim form-E thatthe DLA had taken leave on medical grounds during the period from 04.10.2003 to15.03.2003 (71 days), 01.12.2003 to 31.01.2004 (62 days), 16.02.2004 to 30.0402004(75 days), 16.07.2004 to 30.07.2004 (15 days) and 01.08.2004 to 30.09.2004 (61days).The medical certificate dated 16.02.2004 confirmed that the DLA was suffering

from Chronic Hepatitis c Cirrhosis. Since these facts, which are material forunderwriting of risk, were not disclosed in the DGH of dated 24.06.2005 submitted forgetting the policy revived, revival was set aside. As prior to the revival, the policy hasremained in force for only 2 years and 9 months, nothing stands payable under thepolicy. The duration of policy after revival has been only for 27 days.The leave record given by the Dy. Director, Satpuda Tiger Research, Pachmadi statesthat the DLA had been on sick leave during the period from 04.10.2003 to 15.03.2003(71 days), 01.12.2003 to 31.01.2004 (62 days), 16.02.2004 to 30.0402004 (75 days),16.07.2004 to 30.07.2004 (15 days) and 01.08.2004 to 30.09.2004 (61 days). All theseperiod of leave fall prior to the date of revival of policy but he has not mentioned abouthis suffering from any illness in the DGH dated 24.06.2005 and has stated himself tobe in very good health.Observations of Ombudsman : I have gone through the materials on records andsubmissions made during hearing and summarize my observations as follows:There is no dispute that the Policy No. 351860961 was issued to DLA by theRespondent on 10.03.2002; the same was revived on 24.06.2005 and death of DLAoccurred on 21.07.2005.During hearing, the complainant informed that the DLA was not suffering from anydisease and was in good health at the time of revival of the policy in question.During hearing, the Respondent contended that there is enough evidence confirmingthat the DLA was diagnosed as Complicated Malaria c ARDS c ARF and was sufferingfrom suffering from Chronic Hepatitis c Cirrhosis. However, these facts have beensuppressed in the DGH dated 24.06.2005 submitted for revival of the policy. As suchthe revival under the policy was set aside and as prior to the revival, the policy hasremained in force for only 2 years and 9 months, nothing stands payable under thepolicy.The DLA was diagnosed for aforesaid diseases/ailments and hence the claim wasrepudiated due to concealment of material facts regarding health of DLA. Had theDLA’s ill health and treatment details been brought to the knowledge of theRespondent during revival in DGH submitted by the DLA, the underwriting decision ofthe Respondent would have been different.On scrutiny, it is observed from the Medical Attendent Certificate’s issued by Dr.V.K.Sharma , MD,WHO FELLOW (USA) , Hamidia Hospital , Bhopal has under questionno-4(a) in claim Form B-1 , stated that the primary cause of death is ComplicatedMalaria c ARDS c ARF and secondary cause as Cardio Respiratory Failure, whereas inthe Declaration of Good Health (DGH) report signed by DLA on 24.06.2005 duringrevival shows that the he had never suffered from any ailment whatsoever in the pastand that he was absolutely keeping normal health, hence the contention ofComplainant is not tenable.It is also observed from the leave record given by the Dy. Director, Satpuda TigerResearch, Pachmadi that the DLA had been on sick leave during the period from04.10.2003 to 15.03.2003 (71 days), 01.12.2003 to 31.01.2004 (62 days), 16.02.2004to 30.0402004 (75 days), 16.07.2004 to 30.07.2004 (15 days) and 01.08.2004 to30.09.2004 (61 days). Hence, it is clear that the DLA intentionally suppressed thematerial facts regarding health to the Respondent at the time of reviving the policy inquestion.Insurance is a contract of Utmost Good Faith where both parties are required todisclose all the material facts. No party can be allowed to gain any undue advantage bysuppressing any fact. In the instant case, there are sufficient evidential proofs to show

that the DLA was already suffering from serious ailments but suppressed the same inthe DGH report at the time of revival. Thus, the DLA has misled the Respondent by notproviding vital information regarding his health at the time of revival and hence theRespondent was not able to take proper underwriting decision. Had the facts beenbrought to the knowledge of the Respondent, its underwriting decision would have beendifferent.In view of the circumstances stated above, I am of the considered opinion that thedecision taken by the Respondent is just and fair hence does not require anyinterference. Hence, the complaint is dismissed without any relief.Bhopal Ombudsman CentreCase No.: LI-1140-24/12-07/INDSmt. Rukma Devi DaveVsLife Insurance Corporation of IndiaAward Dated : 23.01.2007Smt. Rukma Devi Dave, resident of Indore (M.P.) hereinafter called Complainant] is thewife of Late Shri Purshottam Dave, Deceased Life Assured (in short DLA). The DLAhad a life insurance policy number 341935832 taken from LIC of India, DO: Indore,CBO-3, Indore [hereinafter called Respondent]. The Policy commenced on 28.01.1996under Endowment without profit with accident benefit Table/Term: 11-20 for SumAssured of 35000/- The DLA expired on 16.09.2005 due to accident. The death claimwas preferred by the Complainant with the Respondent. The basic sum assured of Rs35000/- was paid by the Respondent but the Accident Benefit claim was repudiated onthe grounds that the DLA has not desired to have Accident Benefit in the proposal formsubmitted for insurance. The complainant further added that the premium for accidentbenefit @ Rs1/- per thousand sum assured i.e. Rs 35/- was being accepted sinceinception of the policy which was refunded by the respondent instead of makingaccident benefit claim. Aggrieved by the refusal action of Respondent for accidentbenefit claim, the Complainant has lodged a complaint with this Office seekingdirections to Respondent to settle the accident benefit claim amount under the policy.The complaint was registered and necessary forms were issued to both the parties.Replies were received from both the parties.The Respondent vide their letter dated 23.12-2006 stated that the DLA has not optedfor the accident benefit in the proposal form at the time of taking the insurance policy.Similarly the DLA has also not opted for the accident benefit at the time of executingthe option to alter the policy from without profit to with profit hence the Accident benefitclaim was repudiated. The Respondent further informed that the amount of accidentbenefit premium was wrongly included while calculating the normal premium of thepolicy due to an oversight which was refunded to the claimant.Observations of Ombudsman : I have gone through the materials on records andsubmissions made during hearing and summaries my observations as follows:There is no dispute that the Policies number 341935832 was issued to DLA by theRespondent and DLA met with accident and died on 16.09.2005.During hearing the Complainant stated that the DLA was doing the job of TV repairingat Indore and taken a policy commenced on 28.01.1996 under Endowment withoutprofit with accident benefit Table/Term: 11-20 for Sum Assured of 35000/- for which thepremium paid was including premium for accident benefit @ Rs1/- per thousand sumassured i.e. Rs 35/- was being accepted since inception of the policy and collected the

same till death claim arises. The Respondent also has not reduced this accidentbenefit premium at the time of converting the policy from without profit to with profitand change of mode of premium installment from quarterly to yearly on 17.04.1997.The Respondent has accepted the accident benefit premium continuously for 8 yearsand refused for the accident benefit claim merely on the ground that accident benefitwas not desires by the DLA in the proposal form.During hearing the Respondent stated that the DLA has not opted for the accidentbenefit in the proposal form at the time of taking the insurance policy. Similarly theDLA has also not asked for the accident benefit at the time of executing the option toalter the policy from without profit to with profit hence the accident benefit claim wasrepudiated. The Respondent further informed that the amount of accident benefitpremium was wrongly included while calculating the normal premium of the policy dueto an oversight which was refunded to the Complainant.It is observed from the records that the premium for accident benefit was beingaccepted by the Respondent since the inception of the policy. They have not taken anynotice regarding adjustment of premiums with the premium of accident benefit duringeight years. Further, it appears that the Respondent has neither refunded the premiumof accident benefit accepted by them nor intimated to the DLA at any stage during thisperiod.It is also observed from the copy of policy bond issued where class of assurance wasmentioned as “ENDOWMENT ASSURANCEPOLICY WITHOUT PROFIT (WITHACCIDENT BENEFIT)” and the premium for accident benefit was also being chargedsince beginning of the policy. There after no care was taken to refund the amount ofaccident benefit or to alter the policy bond or any intimation to the DLA in this behalf.In view of the above, it is clear that there is lapse on the part of the Respondent. Thereis no concrete reason found to deny the payment of accident benefit claim by theRespondent even after acceptances of premiums for the period of 8 years.In view of the above, it stands that the Respondent’s decision of repudiation of theaccident benefit claim payment under the Policy is not tenable.Hence, the Respondent is directed to pay the accident benefit claim amount underPolicy No. 341935832 after deducting the refunded premium of accident benefit within15 days of receipt of this order failing which the Respondent shall be liable to payfurther interest at the rate of 9% per annum from the date of this Order till the date ofactual payment.Bhopal Ombudsman CentreCase No.: LI-1126-21/11-07/INDShri Chandraji GurjarVsLife Insurance Corporation of IndiaAward Dated : 14.02.2007Shri Chandraji Gurjar, Resident of Village: Panchdevra, Tehsil: Manasa, Distt.:Neemuch (M.P.) (hereinafter called Complainant) is the brother of Late Shri BhairolalGurjar, Deceased Life Assured (in short DLA). The DLA had a life insurance policynumbered 344481789 taken from LIC of India, DO: Indore, BO: Neemuch (hereinaftercalled Respondent). The Policy commenced on 28.08.2004 under Jeevan Anand PlanTable/Term: 149-21 for Sum Assured of Rs. 1,00,000/-. The DLA expired on 02.08.2005due to high fever. Thus the Policy had run for 11 months & 5 days. The death claimwas preferred by the Complainant with the Respondent but the same was repudiated on

the grounds of suppression of material facts regarding health of DLA and withoutincome at the time of taking policy. The complainant had referred the case toRespondent’s Claims Review Committee for reconsideration which was also upheld bythem on 01.09.2006. Aggrieved from the repudiation action of Respondent, theComplainant has lodged a complaint with this Office seeking directions to Respondentto settle the claim amount.The complaint was registered & necessary forms were issued to both the parties.Replies were received from both the parties.The Respondent vide its self-contained noted dated nil received by us on 26.12.06replied that DLA was having past history of illness since last one year and was nothaving any income which he did not disclose in the proposal. Had he disclosed it,underwriting requirements would have been different. Hence, the claim was repudiateddue to concealment of material facts regarding health of DLA without any income.Observations of Ombudsman : I have gone through the materials on records andsubmissions made during hearing and summaries my observations as follows:There is no dispute that the Policy No. 344481789 was issued to DLA by theRespondent on 28.08.2004 and death of DLA occurred on 02.08.2005.During hearing the complainant contended that the DLA has suffered by Jaundice, afternotice of jaundice he was admitted in Majeji Nursing Home, Manasa from 09.07.2005 to11.07.2005 where 2 bottle blood was given. The Complainant has further informed thatthe DLA never suffered from any disease nor taken treatment or was admitted in anyhospital before taking the policy. The DLA was having sufficient income by way ofkirana shop and through Agriculture income.The Respondent contented during hearing that the DLA was sick prior to date ofproposal without income which he did not disclose in the proposal. Had he disclosed it,underwriting requirements would have been different. Hence, the claim was repudiateddue to concealment of material facts regarding health of DLA without any income.On scrutiny of records, it is observed that no evidential proofs, viz., Investigationreport, Blood test report, X-ray, prescription of doctor treating him, etc. have beensubmitted by the Respondent to prove that the DLA was sick prior to the date of policyin question.The Respondent only tried to strengthen its contention on the basis of Dr. MaheshMajeji’s certificate dated 09.11.05 who certified that the DLA was transferred with 2unit of blood from 09.07.05 to 11.07.05 and the Respondent’s Investigation report wasjust based on Dr. Mahesh Majeji’s report and no other evidence was shownrecommending repudiating of the claim.It is apparent from the above that Respondent’s contention merely on the basis of Dr.Mahesh Majeji’s report that the DLA was transferred with 2 unit of blood from 09.07.05to 11.07.05 is not tenable as DLA was a sick prior to proposal.Had the DLA suffered from the disease since one years as contended by theRespondent, some Investigation reports viz., Blood report/X-ray report, doctor’sprescription with regard to treatment, etc. would have been made available to showthat DLA was actually suffering by any disease since one year.It is further observed that the DLA was admitted in Majeji Narsingh Home, Manasawhere 2 bottle bloods was given during the period from 09.07.2005 to 11.07.2005.It is also observed from the records that the DLA was having saving bank account No –1140 in Ratlam- Mandsaur Kshetriya Gramin Bank, Kajarda from where loan was takenby the DLA. Similarly it is also seen from the records that the DLA was having “ bhoo

adhikar ewam Rin pustika ” for Agriculture land Rakba- 0.433. Hence the contention ofthe Respondent that the DLA was not having any income is not acceptable.The Respondent could not submit any evidence to prove that the DLA was sick prior topolicy in question as well as it is also not acceptable that the DLA was not having sortof income. Further, no malafide intention of DLA is found in taking the policy inquestion.In view of the circumstances stated above, I am of the considered opinion that therepudiation of death claim by the Respondent on this ground stated above is unfair andunjustified.Hence, the Respondent is directed to pay the death claim amount under Policy No.344481789 within 15 days of receipt of this order failing which the Respondent shall beliable to pay further interest at the rate of 9% per annum from the date of this Order tillthe date of actual payment.Bhopal Ombudsman CentreCase No.: LI-1100-21/11-07/GWLShri Dhan Sunder JatavVsLife Insurance Corporation of IndiaAward Dated : 14.02.2007Shri Dhan Sunder Jatav, resident of Gram Bhageh, Tahsil Dabra District Gwalior M.P.(hereinafter called Complainant) is the son of late Smt. Beti Bai Deceased Life Assured(in short DLA). The DLA took a life insurance policy numbered 201247225 from LIC ofIndia, DO: Gwalior, BO- Dabra (hereinafter called Respondent) on 28.10.2004 for SumAssured of 50,000/- under Table/Term: 14-15. The DLA died on 18-03-2005 due toVomitting and loose motion. The complainant has complained that he had preferreddeath claim with the Respondent but the same was repudiated on the grounds ofunderstatement of age by DLA at the time of taking the policy in question. Further thecase was referred to the Claim Review Committee at LIC Zonal Office Bhopal. The ZOCRC in its meeting upheld the DO decision of repudiation on 01-11-2006. Aggrievedfrom the repudiation action of the Respondent, the Complainant has lodged a complaintwith this Office seeking directions to Respondent to settle the claim.The complaint was registered & necessary forms were issued to both the parties.Replies were received from both the parties.The Respondent vide its self-contained note dated 18.12.06 replied that the DLA wasof 63 years age instead of 50 years mentioned by her in the proposal form and she wasresponsible for understating her age by 13 years. Further she was suffering fromparalysis since last three years prior to the date of proposal for insurance. Had shedisclosed her actual age and status of her health in the proposal form, the presentpolicy would not have been issued to her at this age. It is, therefore, evident that shehad made deliberate and incorrect statements and withheld material informationregarding her age and status of her health at the time of affecting the assurance and ifshe had disclosed his correct age and status of her health in the proposal, the proposalwould not have been accepted. Hence in terms of policy conditions and thedeclarations contained in the form of proposal for assurance and personal statement,the claim was repudiated.Observations of Ombudsman : I have gone through the materials on records andsubmissions made during hearing and summaries my observations as follows:

There is no dispute that the Policy No. 201247225 was issued to the DLA by theRespondent on 28.10.2004 and the DLA died on 18-05-2005.During hearing, the Complainant stated that the DLA was illiterate and was sufferingwith paralysis and was not in good health at the time of taking the policy. TheInsurance was done on the basis of declaration of age of the DLA by the Agent whohas filled up the proposal form. The Complainant has further informed that no any otherspecific requirement was called for the age proof either from the agent or from theRespondent during her life time. The Complainant stated that the DLA was not awareabout the information which has been fulfilled by the agent in the proposal forms.The Respondent stated during hearing that at the time of proposal declaration of age ofthe DLA was submitted as age proof where in age was declared as 50 years. But it isobserved from the copy of Voter List of 2003 of “ Vidhan Sabha Kshetra Bhander SerialNo. 665 where in the age of DLA is shown as 62 years in case of proper discloser ofage proposal would not have been completed.It is also seen from the copy of Identity Card issued by the Electoral RegistrationOfficer Bhander where the age of son of the DLA is mentioned as 42 years as on 23-10-2003 which shows that the age of the DLA ( mother of the Complainant ) declaredas 50 years at the time of taking the policy is not tenable.In view of above, it is clear that the DLA has deliberately understated his age todefraud the Respondent in order to accept the proposal and thereby misled theRespondent in taking proper underwriting decision.However, it is further observed that the Respondent has to call for any other alternativedocuments such as copy of Ration Card, copy of Voter list etc.for the verification ofage at the time of underwriting when the DLA was illiterate and submitted thedeclaration of age which the Respondent did not take care.Insurance is a contract of Utmost Good Faith where both parties are required todisclose all the material facts. No party can be allowed to gain any undue advantage bysuppressing any fact. In the present case there is concrete evidence, viz., the copy ofVoter List of 2003 of “ Vidhan Sabha Kshetra Bhander Serial No. 665 to show that theDLA was aged more by 13 years than what was stated by her at the time of takingpolicy. Had the same been brought to the knowledge of the Respondent, theunderwriting decision would have been different.In view of the above, the decision taken by the Respondent in repudiating the deathclaim under Policy No. 201247225 is just and fair hence does not require anyinterference.Bhopal Ombudsman CentreCase No.: LI-1174-21/01-07/BPLSmt. Kailash BaiVsLife Insurance Corporation of IndiaAward Dated : 20.02.2007Smt. Kailash Bai, Resident of Village: Guradiya Rupchand, Tehsil: Ashta, Distt: Sehore(M.P.) (hereinafter called Complainant) is the wife of Late Shri Dev Singh Mewada,Deceased Life Assured (in short DLA). The DLA had a life insurance policy numbered351491649 taken from LIC of India, DO: Bhopal, BO: Sehore (hereinafter calledRespondent). The Policy commenced on 25.12.1997 under Money Back PlanTable/Term: 75-20 for Sum Assured of Rs. 50,000/-. The DLA expired on 18.10.2004due to Vomiting, Diarrhea, and anxiety. Thus the Policy had run for 6 years 9 months &

10 days from date of commencement and 1 year 4 months & 1 day from the date ofrevival. The death claim was preferred by the Complainant with the Respondent but thesame was repudiated on the grounds of suppression of material facts regarding healthof DLA at the time of revival of the policy. The complainant had referred the case toRespondent’s Claims Review Committee for Reconsideration which was also upheld bythem on 28.07.2006. Aggrieved from the repudiation action of Respondent, theComplainant has lodged a complaint with this Office seeking directions to Respondentto settle the claim amount.The complaint was registered & necessary forms were issued to both the parties.Replies were received from both the parties.The Respondent vide its self-contained noted dated 17 th January 2007 received by uson 24.01.2007 replied that as per the claim form B-1, given by Dr. Hira Dalodriya , theDLA was admitted in civil hospital , Ashta on 04.06.2003 and admission entry no. is57/1588. As per Doctor’s statement the DLA had the history of anemia and dysenteryfor past 15 to 20 days. During claim investigation done by the then Sr. BranchManager, Sehore, statements were obtained from the various person residing in thelocality of the DLA where in it has been stated that the DLA was suffering fromdiabetes for past 3 to 4 years and one leg was amputed above knee some 3 year back.However neither the history of Diabetes, nor amputation of one leg and admission incivil hospital, Ashta were mentioned in Declaration of Good Health (DGH) dated16.06.2003 at the time of revival. Had he disclosed it, underwriting requirements wouldhave been different. Hence, the claim was repudiated due to concealment of materialfacts regarding health of DLA.Observations of Ombudsman : I have gone through the materials on records andsubmissions made during hearing and summaries my observations as follows:There is no dispute that the Policy No. 351491649 was issued to DLA by theRespondent on 25.12.1997 and policy was revived on 17.06.2003. The death of DLAoccurred on 18.10.2004.During hearing the complainant contended that the DLA has suffered by weakness andDysentery, he was admitted in Civil Hospital, Ashta, for few hours on 04.06.2003 whereone bottle Glucose was injected and was discharged on the same day after somepreliminary treatment. The Complainant has further informed that the DLA neversuffered by any disease nor taken treatment or he was admitted in any hospital beforetaking the policy.The Respondent contented during hearing that the DLA was having a history ofDiabetes, amputation of one leg and admission in civil hospital, Ashta prior to date ofrevival, which he did not disclose in the DGH submitted for revival of the policy. Had hedisclosed it, underwriting requirements would have been different. Hence, the revivalunder the policy was set aside and paid up value prior to revival was admitted due toconcealment of material facts regarding health of DLA in the DGH.On scrutiny of records, it is observed that the Respondent could not produce anyevidential proofs, viz., case history sheet, Investigation report, Blood test report, X-ray,prescription of doctor treating him, etc. to prove that the DLA was suffering fromDiabetes prior to the date of revival of the policy in question.The Respondent only tried to strengthen its contention on the basis of claim form ‘B’issued by the Dr. Hira Dalodriya dated 21.02.2006 who certified that the DLA wasdiagnosed with anemia c Dysentery and the Respondent’s Investigation report was justbased on statements which were obtained from the various persons residing in thelocality of the DLA where in it has been stated that the DLA was suffering from

diabetes for past 3 to 4 years and one leg was amputed above knee some 3 years backand no other evidence was shown recommending repudiation of the claim. Even thesaid Dr. Hira Dalodriya’s had not mentioned the history of disease, treatment taken,admission in hospital etc. in reply to the question no- 7 (‚ã), (ºã), (Ôã), (ª) & (¾ã).Similarly nothing had been mentioned in reply to question no 10 (‚ã), (ºã), (Ôã) which isrelated with the previous treatments.It is apparent from the above that Respondent’s contention merely on the basis of Dr.Hira Dalodriya’s report that the DLA was diagnosed anemia c Dysentery and theRespondent’s Investigation report was just based on statements which were obtainedfrom the various person residing in the locality of the DLA where in it has been statedthat the DLA was suffering from diabetes for past 3 to 4 years is not acceptable as DLAwas a sick prior to date of revival.Had the DLA suffered from the disease since 3 or 4 years as contended by theRespondent, some Investigation reports viz., Blood report/X-ray report, doctor’sprescription with regard to treatment, etc. would have been made available to showthat DLA was actually suffering by any disease prior to revival.It is further observed from the claim form ‘B’ issued by the Dr. Hira Dalodriya dated21.02.2006 that the DLA was admitted in Civil Hospital, Ashta on 04.06.2003 for oneday and was discharged on the same day. Hence, it is not acceptable that the DLA wasactually suffering by diabetes prior to revival. The Respondent could not submit anyevidence to prove that the DLA was sick prior to date of revival. Further, no amplifiedintention of DLA is found in taking the policy in question.In view of the circumstances stated above, I am of the considered opinion that therepudiation of death claim by the Respondent on this ground stated above is unfair andunjustified.Hence, the Respondent is directed to pay the death claim amount under Policy No.351491649 for basic sum assured within 15 days of receipt of this order failing whichthe Respondent shall be liable to pay further interest at the rate of 9% per annum fromthe date of this Order till the date of actual payment.Bhopal Ombudsman CentreCase No.: LI-1132-21/12-07/RPRSmt. Ratna VermaVsLife Insurance Corporation of India-Award Dated 21-02-2007Smt. Ratna Verma, resident of Village Funda, Post Dewda, Tahsil Patan and Distt.Durg (M.P.) [hereinafter called Complainant] is the wife of Late Shri Bhagwati RamVerma, Deceased Life Assured (in short DLA). The DLA had three life insurancepolicies under salary saving scheme of paying authority C.S.E.B. Durg bearing policynumber 382723326, 382725529 and 382283846 taken from LIC of India, DO: Raipur,BO-Durg [hereinafter called Respondent]. The details of policies are as under.Sr. Policy No. Date of Table/Term SumNo. Commencement Assured1 382723326 28-03-2004 14-10 750002 382725529 28-09-2004 14-12 500003 382283846 28-03-2003 106-15 (12) 50000The DLA expired on 21-09-2005 suddenly due to high B. P. etc. The death claim waspreferred by the Complainant with the Respondent but the same was repudiated on the

grounds of suppression of material facts regarding health of DLA at the time of takingthe policies. The complainant had referred the case to Respondent’s Claims ReviewCommittee for reconsideration which was also upheld by them on 31.10.2006.Aggrieved from the repudiation action of Respondent, the Complainant has lodged acomplaint with this Office seeking directions to Respondent to settle the claim amountunder the policies.The complaint was registered and necessary forms were issued to both the parties.The reply was received from both the parties.The Respondent vide its self-contained note received by this office on 29 thJanuary,2007 replied that as per Medical Attendant and certificate of JL N Hospital,Bhilai the DLA died due to DM, CRF, HTN, CRA and DLA was known patient of DM withHTN at the time of proposing for insurance under the policies. The leave records andmedical certificate shows that the DLA has availed leave on various occasions onmedical ground. The DLA has taken treatment from JL N Hospital Bhilai for nurotisingcallutitiesn Rt thigh and scrotum with DM with HTN since 17-08-2001 to 31-10-2001 ( 2and half months) Further he was not keeping well and taking treatment regularly ondifferent occasions from JL N Hospital, Bhilai. From the above facts it is evident thatthe DLA was suffering from DM, HTN with other ailments since 2001 which were notdisclosed in proposal forms submitted for insurance at the time of taking these threepolicies no. 382723326, 382725529 and 382283846 on 28-03-2004, 28-09-2004 and28-03-2003 respectively. Had the history of DM with HTN has been disclosed at thetime of proposing for insurance, decision for acceptance of the cases would have beenaffected. The DLA did not mention any thing about his past illness. Considering allthese facts LIC repudiate the claim for the reason “Suppression of material facts” on08.03.2006.Further the case was referred to the Claim Review Committee at LIC Zonal OfficeBhopal. The ZO CRC in its meeting upheld the DO decision of repudiation on 31-10-2006.Observations of Ombudsman : I have gone through the materials on records andsubmissions made during hearing and summaries my observations as follows:There is no dispute that the policy number 382723326, 382725529 and 382283846were issued to DLA by the Respondent on 28-03-2004, 28-09-2004 and 28-03-2003respectively and death of the DLA occurred on 21-09-2005.During hearing the complainant stated that the DLA was an employee of C.S.E.B.Patan, Distt. Durg posted as T.A.Grade-1 and he was not suffering from any diseaseand was in good health at the time of taking the policy in question. The Complainantfurther added that the DLA was suffering due to cold, cough and fever occasionally.During hearing, the Respondent contended that there are sufficient evidencesconfirming that the DLA was a known case of DM with HTN prior to taking the policies.However, the history of aforesaid diseases/ailments was not been mentioned by theDLA in the proposal forms dated 28-03-2004, 28-09-2004 and 28-03-2003 respectivelysubmitted for above policies. The DLA was diagnosed for aforesaid diseases/ailmentsand hence the claim was repudiated due to concealment of material facts regardinghealth of DLA. Had the DLA’s ill health and treatment details been brought to theknowledge of the Respondent in the proposal form submitted by the DLA, theunderwriting decision of the Respondent would have been different.It is observed from the Medical certificate dated 17-08-2001 issued by Dr.S.DuttaMedical Officer of C.M. Hospital Bhilai (M.P.) that the DLA was suffering fromnurotising callutitiesn Rt thigh and scrotum with DM with HTN and was advised medical

leave since 17-08-2001 to 31-10-2001 ( 2 and half months) and the same is alsoconfirmed from the employer leave records. Hence the contention of the Complainantthat the leave taken on medical ground for other purpose is not tenable.It is also observed from Claim forms B & B1 dated 13.12.2005 issued by the JL NHospital, Bhilai who attended the DLA during his last illness that the primary cause ofdeath is DM, CRF, HTN, CRA and DLA was known patient of DM with HTN. This clearlyshows that DLA was already suffering from Diabetes Mellitus and Hypertension butintentionally suppressed in the Proposal forms under Policies in question.Insurance is a contract of Utmost Good Faith where both parties are required todisclose all the material facts. No party can be allowed to gain any undue advantage bysuppressing any fact. In the present case, there are sufficient evidential proofs to showthat the DLA was already suffering from serious ailments but suppressed in theProposal forms. Had the same been brought to the knowledge of the Respondent, theunderwriting decision would have been different.In view of the above, the decision taken by the Respondent is just and fair hence doesnot require any interference. The complaint is dismissed without any relief.Bhopal Ombudsman CentreCase No.: LI-1219-21/02-07/GWLSmt. Munni BegamVsLife Insurance Corporation of IndiaAward Dated : 22.03.2007Smt. Munni Begam, resident of Lashkar, Gwalior [hereinafter called Complainant] is thewife of Late Shri Vahid Khan Kadiri, Deceased Life Assured (in short DLA). DLA had alife insurance policy number 382837709 taken from LIC of India, DO: Gwalior, BO-2,Gwalior [hereinafter called Respondent]. The Policy commenced on 15.03.2003 underTable/Term: 14-11 for Sum Assured of 1,00,000/- The DLA expired on 07-10-2004 dueto stomach pain. The death claim was preferred by the Complainant with theRespondent but the same was repudiated on the grounds of suppression of materialfacts regarding health of DLA at the time of taking policy. Aggrieved by the repudiationaction of Respondent, the Complainant has lodged a complaint with this Office seekingdirections to Respondent to settle the claim amount under the policy.The complaint was registered and necessary forms were issued to both the parties.Replies were received from both the parties.The Respondent vide its self-contained note dated 17-02-2007 replied that DLA had notdisclosed his illness in the proposal forms dated 08-03-2003 submitted for insuranceand has stated his state of health was “GOOD”. Had the history of his illness beendisclosed at the time of proposing for insurance, decision for acceptance of the casewould have been affected. Hence, the claim under the policy was repudiated due tonon-disclosure of material facts.The Respondent submitted the Medical certificate dated 04-03-2003 and 08-03-2003for which the DLA availed leave on medical ground from 04.03.2003 to 12.03.2003 withreason Enteric fever. As per leave records obtained from the Employer of the DLA itwas confirmed that the DLA has availed the leaves on medical ground for the period04-03-2003 to 12-03-2003 ( 9 days), 13-03-2003 to 24-04-2003n (43 days)and 01-05-2003 to 27-05-2003 etc.The policy in question was proposed on 08.03.2003 where as the DLA did notmentioned any thing about his past illness. Considering all these facts LIC repudiated

the claim for the reason “Suppression of material facts” regarding his health. Further,he case was referred to the claim review committee at LIC zonal Office Bhopal. The ZOCRC in its meeting upheld the DO decision of repudiation on 22-12.2006.Observations of Ombudsman :I have gone through the materials on records and submissions made during hearingand summaries my observations as follows:There is no dispute that the policy number 202033231 was issued to DLA by theRespondent on 15.03.2003 and death of DLA occurred on 07-10-2004 due to stomachpain.During hearing the complainant contended that the DLA was throughout keeping normalhealth and that he availed leaves from Office on medical grounds for reasons otherthan sickness. The complainant further informed that the DLA was having total fourpolicies bearing no. 202031709, 202031214, 202032003 and 202033231 out of whichthe Respondent has paid the death claim under three policies except the policy no.202033231.The Respondent contented during hearing that the DLA was suffering from entericfever. The policy in question was proposed on 08.03.2003 where as the DLA did notmentione any thing about his past illness. The DLA also availed the leaves on medicalground for the same. Hence the death claim was repudiated for the reason“Suppression of material facts” regarding his health.It is observed from records that DLA was an employee of BSNL as a cashier and hewas suffering from Enteric fever prior to the date of proposal. As per leave recordsobtained from the Employer of the DLA it was confirmed that the DLA has availed theleaves on medical ground for the period 04-03-2003 to 12-03-2003 ( 9 days), 13-03-2003 to 24-04-2003n (43 days)and 01-05-2003 to 27-05-2003.It is also observed from the Medical Certificate issued by Dr. A.K.Jain dated 04-03-2003 and 08-03-2003 for which the DLA availed leaves on medical ground from04.03.2003 to 12.03.2003 with reason Enteric fever, whereas in the proposal formsigned by DLA on 08-03-2003 in which the answer of question no. 11 ( c ) i.e. have youbeen absent for the last 5 years from your duties on the medical ground ? Saying ‘ NO ’to this question shows that the DLA had never suffered from any ailment whatsoever inthe past and that he was absolutely keeping normal health is not tenable.This clearly shows that DLA was already suffering from Enteric fever but intentionallysuppressed in the Proposal forms under Policy in question.Insurance is a contract of Utmost Good Faith where both parties are required todisclose all the material facts. No party can be allowed to gain any undue advantage bysuppressing any fact. In the present case, there are sufficient evidential proofs to showthat the DLA was already suffering from serious ailments but suppressed in theProposal form. Had the same been brought to the knowledge of the Respondent, theunderwriting decision would have been different.In view of the circumstances stated above, I am of the considered opinion that thedecision taken by the Respondent is just and fair hence does not require anyinterference.The complaint is dismissed without any relief.Bhopal Ombudsman CentreCase No.: LI-1231-21/02-07/INDSmt. Leela BaiVs

Life Insurance Corporation of IndiaAward Dated : 23.03.2007Smt. Leela Bai, resident of Gram- khurdi Awar, Tah.- Mahoo Distt.- Indore [hereinaftercalled Complainant] is the wife of Late Shri Mangilal, Deceased Life Assured (in shortDLA). The DLA had a life insurance policies number 344096094 and 344096095 takenfrom LIC of India, DO: Indore, BO Mahoo [hereinafter called Respondent]. The Policiescommenced on 15.03.2004 under Table/Term: 93-25 for Sum Assured of 40,000/-each.The DLA expired on 08-05-2005 due to fever, Altered Sensorium Colvulsion. The deathof DLA occurred after 1 year 1month and 23 days from the commencement of thepolicies. The death claim was preferred by the Complainant with the Respondent butthe same was repudiated on the grounds of suppression of material facts regardinghealth of DLA at the time of taking the policies. Aggrieved by the repudiation action ofRespondent, the Complainant has lodged a complaint with this Office seekingdirections to Respondent to settle the claim amount under the policies.The complaint was registered and necessary forms were issued to both the parties.Replies were received from both the parties.The Respondent vide its self-contained note received on 12-03-2007 replied that DLAhad not disclosed his illness in the proposal forms dated 10-03-2004 submitted forinsurance and has stated his state of health was “GOOD”. Had the history of his illnessbeen disclosed at the time of proposing for insurance, decision for acceptance of thecase would have been affected. Hence, the claim under both the policies wasrepudiated due to non-disclosure of material facts.The Respondent submitted the records of M.Y.Hospital, leave records from theEmployer with Medical certificate from Dr. J.L.Patidar dated 05-05-2004 for which theDLA availed Earn leave on medical ground from 01-03-2004 to 05-05-2004 for 66 dayswith reason Pyrexia of unknown origin (PUO).The policies in question were proposed on 10-03-2004 where as the DLA did notmentioned any thing about his past illness. Considering all these facts LIC repudiatedthe claim for the reason “Suppression of material facts” regarding his health. Further,the case was referred to the claim review committee at LIC zonal Office Bhopal. TheZO CRC in its meeting upheld the DO decision of repudiation on 22-12-2006.Observations of Ombudsman : have gone through the materials on records andsubmissions made during hearing and summaries my observations as follows:There is no dispute that the policy number 344096094 and 344096095 were issued toDLA by the Respondent on 15.03.2004 and death of DLA occurred on 08-05-2005 dueto fever, Altered Sensorium Convulsion.During hearing the complainant stated that the DLA was an employee of P.H.E.Deptt.as Helper posted at Mandleshwar and he was not suffering from any disease and wasin good health at the time of taking the policies in question. The Complainant furtheradded that the DLA was suffering from cold, cough and fever occasionally.During hearing, the Respondent contended that there are sufficient evidencesconfirming that the DLA was suffering from fever, Altered Sensorium Colvulsion prior totaking the policies. However, the history of aforesaid diseases/ailments was notmentioned by the DLA in the proposal forms dated 10-03-2004 for both the policies.The DLA was diagnosed for aforesaid diseases/ailments and hence the claim wasrepudiated due to concealment of material facts regarding health of DLA. Had theDLA’s ill health and treatment details been brought to the knowledge of theRespondent in the proposal form submitted by the DLA, the underwriting decision ofthe Respondent would have been different.

It is observed from the Medical certificate dated 15-07-2001 issued by the Dr.R,M.Prajapati Medical Officer of Primary Health Centre, Manpur. (M.P.) that the DLAwas suffering from Viral Hepatitis and was advised medical leave since 15-07-2001 to31-08-2001 ( 2 and half months) and the same is also confirmed from the employerleave records. It is also seen from the case history sheet of M.Y.Hospital where theDLA diagnoised as fever c Altered Sensorium Colvulsion, cerebral Malaria (chronicAlcohaolic). Hence the contention of the Complainant that the leaves taken on medicalground for other purposes is not acceptable.It is also observed from the Medical Certificate issued by Dr. J.C.Patidar medicalOfficer PHC Somakhedli Tah. Mandleshwar dated 05-05-2004 for which the DLAavailed leave on medical ground from 01-03-2004 to 05-05-2004 with reason Pyrexia ofUnknown origin and bed rest was advised for this period, whereas in the proposal formsigned by DLA on 10-03-2004 in which the answer of question no. 11 (c) i.e. “ Haveyou been absent for the last 5 years from your duties on the medical ground? ”, Saying‘ NO ’ to this question shows that the DLA had never suffered from any ailmentwhatsoever in the past and that he was absolutely keeping normal health is nottenable.This clearly shows that DLA was already suffering from fever, Altered SensoriumColvulsion/serious ailments but intentionally suppressed in the Proposal forms underPolicies in question.Insurance is a contract of Utmost Good Faith where both parties are required todisclose all the material facts. No party can be allowed to gain any undue advantage bysuppressing any fact. In the present case, there are sufficient evidential proofs to showthat the DLA was already suffering from serious ailments but suppressed in theProposal forms. Had the same been brought to the knowledge of the Respondent, theunderwriting decision would have been different.In view of the circumstances stated above, I am of the considered opinion that thedecision taken by the Respondent is just and fair hence does not require anyinterference. The complaint is dismissed without any relief.Bhopal Ombudsman CentreCase No.: LI-1238-21/02-07/GWLSmt. Indra Devi KandhaVsLife Insurance Corporation of IndiaAward Dated 26-03-2007Smt. Indra Devi Kandha, resident of Datia [hereinafter called Complainant] is the wifeof late Shri Hasmathram Kandha, Deceased Life Assured (in short DLA). The DLA tooka life insurance policy numbered 201211195 under Table/Term 75-20 for sum assuredof Rs 100000=00 on 28.12.95 from LIC of India, Divisional Office: Gwalior, BranchOffice: Dabra [hereinafter called Respondent]. The Policy lapsed due to non-paymentof half yearly premiums due for 06/96 to 012/99 and subsequently the same wasrevived on 03.01.2000 on the basis of Declaration of Good Health (in short DGH). TheDLA died on 08.01.2000 due to heart attack and death claim was preferred by theComplainant with the Respondent. The complainant has complained that the same wasrepudiated by the Respondent. The complainant had referred the case to Respondent’sClaims Review Committee for reconsideration which was also upheld by them on 01-11-2006. Aggrieved by the repudiation action of the Respondent, the complainant haslodged a complaint with this Office seeking directions to Respondent to settle the claimamount.

The complaint was registered & necessary forms were issued to both the parties.Replies were received from both the parties.The Respondent vide its self-contained noted dated 26-02-2007 received by us on 28-02-2007 replied that Policy numbered 201211195 was issued to DLA on 28.12.95 for asum assured of Rs. 100000/-. Then, the policy lapsed and the same was revived on03.01.2000. Thus the Policy has run for 4 years 1 month and 10 days from the date ofcommencement and only for 5 days from the date of revival. The matter was underinvestigation as there is a difference in the signature of DLA on DGH for revival andthe death certificate was prepared after 9 months of death of DLA. Owing to the abovereasons, the claim settlement was delayed and now they have repudiated the deathclaim on the ground that the signature done on DGH dated 03-01-2000 is not of theDLA.Observations of Ombudsman : I have gone through the materials on records andsubmissions made during hearing and summaries my observations as follows:There is no dispute that the Policy No. 201211195 was issued to DLA by theRespondent under Money Back Plan on 28-12-1995 for sum assured of Rs. 100000/-.The Policy was revived by DLA on 03.01.2000 and the DLA died on 08.01.2000 due toheart attack.During hearing the complainant contended that the DLA was throughout keeping normalhealth and has a kirana shop at Dinara where he used to go there daily. TheComplainant has further informed that the DLA never suffered from any disease nortaken treatment or was admitted in any hospital before reviving the policy. The death ofDLA was due to heart attack.During hearing the Respondent stated that the policy was commenced on 28-12-1995.The policy was lapsed since Hly due 06/96 and was revived by paying arrears ofpremium for due 06/96 to 12/99 on 03-01-2000 on the basis of DGH. The respondentfurther informed that the signature of DLA on the DGH dated 03-01-2000 was nottallied with the signature on the proposal of policy in question. Hence the death claimwas repudiated by the Respondent.It is observed from records that the claim was repudiated by the Respondent due to thereasons that the signature of DLA differs in DGH for revival. On scrutiny, it is observedthat the Date of Death of DLA is 08.01.2000 and the death certificate is dated22.09.2000 but the Respondent has not raised any objection about the issue of deathcertificateIt is observed that the Respondent has taken the decision of repudiation on 11-02-2006on the basis of report of hand writing expert dated 30-12-2005 which was already lyingwith them and not any extra efforts were made to establish the signature of DLA fromany other admitted proof of his signature such as bank account, school records, rationcards etc. and the decision of repudiation was taken only after the order from thisforum issued on 31-01-2006. If the decision was to be taken merely on the HandWriting Expert’s they could have taken the decision earlier, which shows unreasonabledelay in deciding the claim.It is seen from records that when the DLA was ready to revive his policy by paying theamount of Rs 32232=80 then there is no point that he could have not signed the DGHsubmitted at the time of revival with 3 ½ years premium in arrears, even the originalclaim forms were also misplaced. It may also possible that the DGH originallysubmitted by the DLA is replaced by the Respondent to strengthen the repudiationaction.

It has also not been verified by the Respondent that the signature of witnesses on theDGH were by unknown person and not by the agent or Development Officer of LIC ofIndia. Further, It is found from the records that the there is no such person namedRamprasad witnessed who signed on DGH is residing at the address Ram kirana store,Datia denied that he has signed on any such DGH. On the contrary the person whocould have signed the DGH confirmed that he had not signed such DGH which was alsoconfirmed by the investigating officer.Thus there is no concrete reason found to accept the delay in repudiation of claim bythe Respondent even after a period of 5 years and the ground for repudiation. TheRespondent has failed to adduce any documentary proof to show that there wasmalafide intention of DLA on any count at the time of reviving the policy.In view of the above, it stands that the Respondent’s decision of repudiation of thedeath claim payment under the Policy is not just and fair.Hence, the Respondent is directed to pay the death claim amount under Policy No.201211195 within 15 days of receipt of this order failing which the Respondent shall beliable to pay further interest at the rate of 9% per annum from the date of this Order tillthe date of actual payment.Bhubaneshwar Ombudsman CentreCase No. : 24 –001-0331Sri Arjun SahuVsLife Insurance Corporation of IndiaAward Dated : 10.10.2006The deceased life assured Lilabati Behera had obtained two Bima Kiran Policies underTable & Term 111-29 from Phulbani Branch of LIC of India vide Policy Nos. 570389697& 570389948 commencing from 24.12.99 & 15.1.2000 for assured sum of Rs.100000/-and Rs.200000/- respectively. She had also obtained one Jeevan Sathi policy underTable & Term 89-20 from the same branch on 24.12.99 for an assured sum ofRs.100000/- vide policy no. 570389802. In all the three policies Complainant wasnominated as beneficiary in the event of her death. Due to non payment of premiumsthe above three policies were lapsed w.e.f. Dec’02,Jan’03 and Dec’02 respectively andon payment of arrear premiums with interest and submission of PSRH the policies wererevived on 21.1.2004.Unfortunately the assured died on 7.12.2004. The death claims lodged by theComplainant were repudiated by the Insurer on the ground interalia that the Assuredhad suppressed material fact of pre-existing disease at the time of revival.The complaint was taken up for hearing on 19.6.2006 in presence of both parties .Itwas contended by the Complainant that factum of the pre-existing disease was notknown to the assured and she had paid the premiums regularly through PanchananSahu, Agent of the Insurer. The agent misappropriated the premiums and abscondedthereafter for which the policies lapsed.The representative of the Insurer on the other hand submitted the assured wassuffering from Breast High grade Sarcoma on the date of revival which material factwas not disclosed in the PSRH.Admittedly three lapsed policies were revived on 21.1.2004 on payment of arrearpremiums with interest and submission of PSRH stating therein that she was in soundhealth. The Xerox copies of medical papers and certificate of TMH, Mumbai producedby the Insurer reveal that the assured was a known case of breast (L) high grade

sarcoma w.e.f. 10.2.2002 and she was referred to OPD on 21.1.2004 and undergonesurgery on 24.2.2004. The three conditions for revival envisaged in the policy are :- thestate of health on the date of revival, any change in occupation and factual payment ofthe arrears. In the present case the assured was suffering from Breast Cancer andvisited OPD of TMH on the date of revival which material fact was suppressed in thePSRH.The repudiation therefore cannot be faulted on any score. Regarding misappropriationof premiums by the agent C.V.O. of the Insurer may make a thorough enquiry and takeappropriateaction at his end.Bhubaneshwar Ombudsman CentreCase No. : 24 -264Sri Alekha Chandra BhoiVsLife Insurance Corporation of IndiaAward Dated : 13.10.2006The deceased life assured Kabuli Kandi, while serving as Anganwadi Worker underBalikuda Block had obtained a Bima Kiran Policy under T&T 111-20 commencing from28.7.97 for an assured sum of Rs.50000/- under Mly SSS mode from JagatsinghpurBranch of LIC of India. She had nominated her husband, the Complainant asbeneficiary in the event of her death vide policy no.581520114.Unfortunately the assured died on 13.10.02 & the complainant as nominee lodged theclaim with the insurer. The Insurer repudiated the claim on the ground interalia that thepolicy had lapsed w.e.f. March’02 due to non payment of premiums.The complaint was taken up for hearing in presence of both parties on 26.6.2006. Itwas contended by the Complainant that employer was responsible for non remittanceof premiums. The Insurer on the other hand submitted that the employer stoppeddeducting premiums from the salary of the assured w.e.f. Nov’2001. The assured paidpremiums directly for months Dec’01 to Feb’02 only and discontinued thereafter forwhich the policy lapsed.Under SSS mode, the employer gives facilities to the representatives of the Insurer tocontact the employees to offer life insurance cover to them. Premium amount, if anemployee agrees to insure under the scheme are to be deducted every month fromemployee’s salary and the amount so collected are paid to the insurer by one chequeby the employer. This ensures for the employee regular payment of premium atconcessional rates.The employee policy holder is also required to submit letter of authorization alongwiththe proposal. It emanates from the bi-partite agreement letter of the employer andauthorization of the employee that the employer undertakes to deduct premium forwhich no notice or receipt will be issued to the employee. The assured in the letter ofauthorization has undertaken that she shall be entirely held responsible for anyconsequence on account of non payment of premiums for reasons beyond the controlof the employer viz ;- in the event of proceeding on leave without pay or drawingadvance salary without deduction of premiums or withdrawing the authorization by adue notice to the insurer after the initial period of three years or in the event of herleaving service.The assured was a low paid employee getting a paltry honorarium of Rs. 438/- p.m.and mly. premium under the policy was Rs.62/- only. The employer deducted premiumfrom her salary up to Oct’01. Thereafter there was abnormal delay in drawal and

disbursement of salary as reported by CDPO, Balikuda, the employer. It is evident fromthe statement received from the employer that they were careless and most irregular indrawal and disbursement of the salary. The employer was never bothered to intimatethe insurer about irregular drawal and disbursement of salary. The bi-partite agreementdoes not also whisper a word about arrangement for payment of premium in the eventof delayed drawal and disbursement.It is the duty of the employer to draw and disburse salaries of their employees in time.Delayed payment and disbursement of assured’s salary from Nov’01 to Sept’02 is agross negligence on the part of the employer. Hence the blame for non payment ofpremium can not be laid at the door of a low paid employee like the assured. TheInsurer also should not side track the laws set down by the apex court on this issue inthe case of DESU vrs. Basanti Devi and Another(1999) NJC SC 539. It is thereforefound to be a fit case for ex-gratia award.An ex-gratia award of Rs.25000/- under Rule 18 of RPG Rules’98 is given to theComplainant.Bhubaneshwar Ombudsman CentreCase No. : 21-001-0165Sri Achutananda SwainVsLife Insurance Corporation of IndiaAward Dated : 12.10.06The deceased life assured Biswaranjan Swain had obtained a Jeevan Mitra(TrippleCover) Endowment Assurance with Profit Policy under T & T 133-25 for anassured sumof Rs.50000/- commencing from 27.11.02 nominating his brother Manas Ranjan Swainas beneficiary in event of his death vide Policy No.585022415.As ill luck would have it, the assured died on 4.6.2003. The nominee lodged deathclaim with the Insurer. The Insurer repudiated the claim on the ground interalia that theassured committed suicide within the operative period of suicide clause.The complaint was taken up for hearing on 19.6.2006 in presence of both parties. TheComplainant contended that the assured died out of suspected poisoning whereas therepresentative of the Insurer dubbed it as a case of suicide.Admittedly on 3.6.2003 the assured traveled from Bhubaneswar by a Cuttack boundbus and while alighting at Pratapnagari at about 7pm fell down unconscious. He wasrushed to SCB Medical College & Hospital, Cuttack where he died at 3.45 a.m on4.6.2003 while taking treatment. Doctor conducting autopery over the dead body of theassured reserved opinion as to cause of death. Consequent upon death of the assuredManglabag P.S. U.D. Case No.516 dtd.4.6.2003 was registered. The investigatingofficer submitted final report stating it to be a case of suspected poisoning.Ordinarily nobody commits suicide inside a bus during a short journey. The insurer hasnot made any investigation in to the matter nor they have produced any proof insupport of their contention that the assured committed suicide. In the absence of anyevidence to the contrary, Final Report submitted in the U.D.Case No. 516 dtd.4.6.2003, holding the death of the assured as a case of suspected poisoning isaccepted.The repudiation is set aside.Bhubaneshwar Ombudsman Centre

Case No. : 21-001-0168Sri Lingaraj SahooVsLifeInsurance Corporation of IndiaAward Dated : 18.10.06The deceased life assured Rashmi Ranjan Sahoo had obtained a Bima Kiran Policy on28.9.1999 under Table & term 111-30 for an assured sum of Rs. 200000/- under Qlymode of payment from LIC of India, Phulbani Branch vide Policy No. 570389020nominating his father, the Complainant as beneficiary in the event of his death. Due tonon payment of premium the polcy lapsed w.e.f 12/2000 and the assured got it revivedon 17.9.2002 on payment of arrear premiums with interest and submission of PSRHand Full Medical Report. Unfortunately the assured died on 27.11.02. The Complainantlodged death claim which was repudiated on the ground interalia that the assured hadsuppressed material facts relating to pre-existing disease at the time of revival.A hearing was held on 19.6.2006. It was contented by the Complainant that theassured died at home out of encephalitis and had no pre-existing disease at the time ofrevival. The Insurer submitted that the assured was suffering from Brain Tumour priorto date of revival.The death of the assured on 27.11.2002 at his native place is not disputed. The disputecenters round whether he was suffering from Brain Tumour on the date of revival asalleged by the Insurer. Based on the statements of two villagers to the InvestigatingOfficer of the Insurer, it was contended that the assured died 16 months after operationof brain tumour. The two witnesses have not filed any affidavit before this forum. TheInsurer has also not produced any medical evidence in support of their plea that theassured had undergone brain tumour operation 16 months prior to his death. Thedoctor of the Insurer Dr. P.K.Das code no. 8480 who had examined the assured on14.9.2002 i.e 3days prior to the revival found him in good health.The conditions prescribed in the policy for revival are : the state of health on the deathof revival any change in occupation and factual payment of arrears. In the present caseas certified by the doctor of the Insurer, the assured was in good health on the date ofrevival. The repudiation therefore is arbitrary. The Insurer is directed to pay the deathclaim of Rs.200000/- along with interest @ 5% p.a. from the date of complaint i.e.27.4.2005 till payment to the Complainant.Bhubaneshwar Ombudsman CentreCase No. : 21-001-0214Smt.Sumitra PandaVsLife Insurance Corporation of IndiaAward Dated : 13.12.06On 15.3.2003 the deceased life assured Basudev Panda had obtained a JeevanSurabhi Plan under Table & Term 107-20 for an assured sum of Rs. 40000/- undermonthly mode of payment from LIC of India Rayagada Branch vide policy no.570945079 nominating the Complainant as beneficiary in the event of his death. As illluck would have it the assured died in a road accident on 17.7.2004. The assured wasdefaulted in paying premiums and on the same day the premiums for the gap periodfrom 3/04 to 6/04 was paid at 1.31 PM on behalf of the assured. In Oct’04 the

There was no dispute that the DD for the premium amount Rs. 4409/- was prepared on29.3.2004 by SBI Nowrangpur which is the nodal agency of the Insurer. The assureddied on 30.8.2004 after payment of premium. The assured had no role to play and theball was on the court of the insurer. In spite of repeated requests and longadjournment, the nodal agency ( SBI Nowrangpur ) avoided to furnish date of despatchof draft to the Insurer.Explanation to Section 64 VB of Insurance Act 1938 provides “ where the premium istendered by M.O. or cheque sent by post, the risk may be assumed on the date onwhich the money order is booked or the cheque is posted as the case may be.In the present case premium DD was prepared on 29.3.2004 and the assured died 5months thereafter. The nodal agency avoided to state the date on which the DD wasdespatched to the Insurer. Therefore the adverse presumption u/s 114(g) of IndianEvidence Act is to be drawn against the Insurer.The TPA is not a party to the contract. The assured is in no way concerned with a thirdparty. The Assured has performed his part of the contract. The contract therefore cannot be dubbed as unconcluded for the remissness of the law. The repudiation istherefore not sustainable in law.The Insurer is directed to settle the claim by liquidating the outstanding loan withinterest.Bhubaneshwar Ombudsman CentreCase No. : 21-009-0172Smt. Modulu EpiliVsBajaj Allianz Life Insurance Co.Ltd.Award Dated : 30.01.07The Complainant is the widow of deceased life assured Epili Judhisti who had obtaineda Risk-Care- Economy non participating policy for 15 years term for an assured sum ofRs.4,50,000/- commencing from 13.11.2003 from Bhubaneswar Branch of Bajaj AllianzLife Insurance Co. Ltd. vide Policy No. 3277432 nominating the Complainant asbeneficiary in the event of his death. Unfortunately the life assured died on 29.11.2003due to accidental fall from the stair case of the house. The Complainant as nomineelodged the death claim which was repudiated by the Insurer on the ground interalia thatit was an unconcluded contract.The Complaint was taken up for hearing in presence of both parties. It was contendedon behalf of the Complainant that the assured died on 29.11.2003. The date of riskstated in the policy document being 21.11.2003, the contract was concluded andbinding on the Insurer.It was submitted by the Insurer that though the SUC was Rs.4,50,000/- the TASAincluding previous policies comes toRs.9,00,000/- for which medical examination ismandatory before acceptance of the proposal. In response to their letter dt.23.12.2003, the medical examination report of the assured was submitted in theprescribed format issued by Dr. R.K.Mohapatra of Berhampur certifying good healthwhere upon the policy document in question was issued on 14.4.2004 stating date ofrisk as 21.11.2003. Subsequently on lodging of claim , it came to light that the assuredhad died on 29.11.2003 i.e prior to the alleged medical examination. The Complainantpracticed fraud in obtaining the policy by producing a created medical examinationreport on 12.4.2004 i.e after death of the assured for which the claim was repudiated.

The Corporate Agents’ Manual produced on behalf of the Complainant provides formedical examination for SUC when modified by TASA to the tune of Rs.9,00,000/-. Inthe present case the TASA being Rs.9,00,000/- medical examinations of the proposeris required as per the underwriting procedure of the Insurer. On 12.4.2004 the Insurerreceived the medical examination report of the Assured. The copy of death certificatereveals that the assured had died on 29.11.2003 at Rangunipali. Evidently the assuredwas not alive on the alleged date of medical examination. The medical report thereforewas a created one.The policy was issued on 14.4.2004 showing 21.11.2003 as date of risk as conclusionof the contract which was dependent on medical examination report of the assured. Asthe medical examination report was created after death of the assured, the policy wasobtained by fraud and as such void ab-initio.The repudiation therefore cannot be assailed.Bhubaneshwar Ombudsman CentreCase No. : 21-002-0203Smt.Ashalata ParidaVsSBI Life Insurance Co.Ltd.Award Dated : 29.01.07The Complainant is the widow of deceased proposer Prasanta Kumar Parida who hadobtained a housing loan of Rs.12,50,000/- from SBI, Cuttack City Branch on 8.7.2004.A sum of Rs. 55,288/- was debited from his loan A/c. as premium for coverage under“SBI Life Super Suraksha group Insurance for housing loan borrowers of SBI” for anassured sum equivalent to outstanding loan amount including interest as per EMIschedule during tenure of loan.As ill luck would have it the proposer died on 27.3.2005 due to Cardiac Arrest beforeissuance of Certificate of Insurance. The Complainant as nominee lodged death claimwhich was repudiated on the ground interalia that it was an unconcluded contract asthe proposer had not undergone the required medical examination.In a hearing held on 28.11.2006 it was contended on behalf of the Complainant that nonotice for medical examination was issued to her late husband whereas therepresentative of the Insurer contended that their agent (CIF) had noticed the proposerfor undergoing medical examination.Sub clause IV of Clause 2 of Product feature of the scheme states that for loan amountabove 7.5 lakh the proposer is required to undergo a medical examination and the costof medical examination will be borne by SBI Life. As the proposer had taken loanamount exceeding 7.5 lakh, he was required to undergo medical examination as per thepolicy condition.The representative of the Insurer stated during hearing that the proposer was given alist of panel doctors with advise to get himself medically examined. It is stated in theirSCN that their agent Certified Insurance Facilitator (CIF) had issued notice to theproposer to undergo medical examination. But these bald statements uncorroboratedby any documentary proof are not worthy of credence. The Complainant stated duringhearing that Sri A.K.Chatterjee, BM,SBI Cuttack City Branch had told the proposer thathe will get notice for medical examination from the Insurer. The Complainant has alsofailed to substantiate her contention.It is therefore manifest that both sides were negligent in conducting medicalexamination. Since medical examination is a precondition for acceptance of the

proposal the contract remains unconcluded & as such the repudiation cannot be faultedan any score. The Complainant, if so likes may take legal action in appropriate forumagainst the concerned officers of the Insurer responsible for keeping the premiumamount of the proposer on hold for more than eight months without processing for hismedical examination.The Complaint stands dismissed.Chandigarh Ombudsman CentreCase No. : LIC/192/Srinagar/Jammu-II/21/07Ramesh Kumar BhagatVsLife Insurance Corporation of IndiaOrder dated: 22.11.06FACTS : Shri Ramesh Kumar Bhagat’s wife Late Smt. Indrani Bhagat had taken twopolicies bearing nos. 140956473 and 140799409 from Branch Unit-II, Jammu. Hestated that his wife was employed in Doordarshan Jammu for 22 years and she did notavail any type of medical leave during her service. He further stated that no materialfacts/information regarding her health were withheld at the time of revival of insurancepolicies. He, however, admitted that his wife was not feeling well for the last twoyears. Though doctors were consulted and treatment was taken, she could not recoverand died. The death claims filed by him were repudiated. Since he was not satisfiedwith the decision of the insurer, he sought intervention of this Forum in getting thedeath claims paid to him.FINDINGS : On referring the case to the insurer it was informed that the death claimwas repudiated after it was found that deceased life assured had withheld materialinformation regarding her health at the time of revival of both the policies on19.04.2002 (140956473 ) and on 28.10.2002(140799409) respectively and revivalswere effected on the basis of Declaration of Good Health. It was informed that thepolicyholder died on 02.05.2005. The investigation conducted in this case revealedthat deceased life assured had remained under treatment for chronic renal failure from30.08.1999 to 08.09.1999 and from 15.02.2001 to 01.03.2001. While both theseperiods fall prior to the date of revivals, this fact was not disclosed in the D.G.H. form.It was denied that LIC office had any record of DLA not keeping good health during herlife time. It was categorically stated that such records were collected only after deathof life assured. He further informed that the claims were repudiated on the basis ofconcealment of material facts and claimant has accordingly been informed. Thecomplainant stated that as per Section 45 of Insurance Act, 1938, the onus of provingthat there was a fraudulent and intentional misrepresentation of fact or concealmentlies on the insurer. Otherwise, the insurer cannot call the policy in question afterexpiry of period of two years. In the instant case, both the policies had run for morethan two years from the date of revival. The representative of insurer mentioned thatthere was a medical certificate to show that the deceased whose life was assured wassuffering from renal diseases, but the certificate was not enough to prove that it was achronic disease. It only proved that the treatment was taken and subsequently patientwas declared fit for active service.DECISION : Held that since the policyholder had not suppressed material factsintentionally or fraudulently, the insurer was under liability to make payment of full sumassured under both the policies mentioned above to the nominee of Smt. IndraniBhagat. Hence ordered that payment be made to the nominee.

Chandigarh Ombudsman CentreCase No. : LIC/333/Ludhiana/Jagraon/21/07Charanjit KaurVsLife Insurance Corporation of IndiaOrder dated: 24.1.07FACTS : Smt. Charanjit Kaur’s husband Late Shri Sardar Surjit Singh had taken apolicy bearing no. 161493098 from Branch Office, Jagraon for sum assured of Rs.25,000/- with DOC 28.12.2002. The policy was revived on 24.05.2005. He died on27.06.2005. She stated that the premiums were paid regularly under the policy. Shelodged death claim with relevant documents which was repudiated on the ground ofsuppression of material facts at proposal stage. She vehemently denied allegation thather husband was habitual of consuming drugs and selling them. She came to know ofthis allegation when a fake case was registered against him.FINDINGS : The insurer informed vide letter dated 18.12.2006 the DLA died in policecustody on 27.06.2005. He was detained by the police under section 15 of N.D.P.S.Act. He was also detained by the police on 12.08.2000. It was further informed that aninvestigation was conducted which revealed that DLA was in the habit of taking excessliquor and drugs. He was admitted in Rajindra Hospital, Patiala for treatment ofdiseases because of excess liquor and drugs. The policy was revived on 24.05.2005.However, these facts were not disclosed by him at the time of revival of the policy. Theinsurer stated that the policy was in force on the date of death. There was intimationgiven by police authorities that the DLA was a habitual alcoholic and consumer ofdrugs etc. It was found that no proof of pre-existing disease could be established bythe representative of insurer. The record given in the claim form by the medicalauthorities was based on the information furnished by police attendant who was not amedical practitioner. While it may be a fact that the DLA was selling drugs etc., but thatrelated to his activities for which the police had already registered a case against himand it had no relevance with the insurance policy as the terms of insurance policy donot mention that insured should not indulge in illegal activities at the time of taking upthe insurance policy for basic sum assured.DECISION : Held that the claim of the complainant for payment of admissible amountunder the basic sum assured was tenable. Hence ordered that the insurer should makepayment of admissible amount for basic sum assured along with accrued bonus.Chandigarh Ombudsman CentreCase No. : LIC/356/Chandigarh/Malerkotla/21/07Smt. SariyaVsLife Insurance Corporation of IndiaOrder dated: 27.2.07FACTS : Smt. Sariya who happens to be the nominee under the policy stated that herhusband had taken two policies; one for himself and the other on the life of his son inthe month of June 2004. He had submitted driving licence as age proof for himself andration card for his son. Both the age proofs were accepted by the insurer and policieswere issued. Unfortunately, the complainant’s son died on 03.05.2005 due to heartattack. During investigation, the insurer procured his date of birth from the schoolrecord which differed from his actual date of birth. She further stated that there was noadverse family history or health problem in her entire family. The insurer had declined

the claim stating that her son being a minor at the time of proposal was not legallyqualified to contract. Being an illiterate family, they were not aware of the complicationdue to overstatement and there was no intention to deceive the insurer.FINDINGS : The insurer informed that Shri Iyameen (DLA) was issued a money backpolicy for sum assured of Rs. 1,05,000/- with DOC 23.06.2004. It was further informedthat in the policy papers DLA stated his date of birth as 05.01.1984 and submitted theration card dated 05.07.1995. Accordingly, the age nearer birthday comes to 20 yearson the date of proposal. Just after 10 months 10 days, LA died due to heart attackwithout any medical aid. Being an early claim, bonafides were investigated and it wasfound to be a case of overstatement of age by three years. As per school record, dateof birth is 09.01.1987 and not 05.01.1984 as stated by DLA in his proposal papers.Hence, accordingly age nearer birthday as on date of risk commenced comes to 17years 05 months 14 days i.e. minor. Therefore, as per policy contract, minor had nocapacity to enter into any contract. Hence, the contract was void ab initio. Therefore,considering all facts of the case, the Competent Authority decided to repudiate theclaim and the same was duly conveyed to complainant vide letter dated 31.12.2005. Ona query whether any certificate from registrar of birth or death is available, the replywas in the negative. The complainant pleaded that the actual date of birth was notknown and assessed date of birth was given both in ration card and to schoolauthorities. The DLA had given a declaration without fully comprehending thequestionnaire regarding the age proof. It was found that the basic issue was correctage of DLA at the time of taking insurance cover. The complainant could not produceany documents from the office of registrar of deaths and births. The insurer wasadvised to depute a responsible officer to the village/ hospital where the DLA was bornto ascertain the correct age and obtain a proof to that effect.DECISION : Held that based on above document the claim be settled on merits within45 days. In case no document was made available as proof of date of birth the presentrepudiation should hold good.Chandigarh Ombudsman CentreCase No. : LIC/407/Ludhiana/Khanna/21/07Kulwant KaurVsLife Insurance Corporation of IndiaOrder dated: 30.3.07FACTS : Smt. Kulwant Kaur’s husband Late Shri. Kulwant Singh purchased a policybearing no. 300175685. He expired on 14.4.05. The requisite documents pertaining toclaim were submitted in the insurer’s office for settlement of claim, but the same wasrepudiated in February’06. She urged intervention of this forum in settlement of claimin her favour.FINDINGS : The insurer informed that the DLA submitted proposal dated 20.12.04 forRs. 1,50,000 and stated that he had no problem of sugar and BP at the time ofproposal and even earlier. However, DLA had high BP since last 5 years and sugarsickness since 1.1.2002. The insurer informed that they had sufficient proof fromtreating doctor which confirms that DLA was suffering from sugar and high BP. Hencethe claim was repudiated accordingly as DLA misstated and concealed facts regardinghis adverse physical history knowingly. Hence Section 45 of Insurance Act was alsooperative in this death claim under the policy.DECISION : Held that the repudiation of claim by the insurer was in order. No furtheraction is called for and the complaint was dismissed.

Chandigarh Ombudsman CentreCase No. : LIC/425/Ludhiana/24/07Sapna RaniVsLife Insurance Corporation of IndiaOrder dated: 30.3.07FACTS : Smt. Sapna Rani’s husband Late Shri. Nirmal Jeet Dhand had taken threepolicies bearing nos. 300494770, 300493932 and 300493933. The death claim filedunder the said policies was repudiated by the insurer on the ground of deceasedhaving withheld correct information regarding health at the time of effecting the policy.The complainant stated that her father-in-law and her husband had given correctinformation to the agent and the LIC officer about the admission in the hospital andwas operated thereafter. She stated that she was a witness to the above informationbeing given to the agent and LIC officer. Now they are not at fault. She urgedintervention of this forum in settlement of claims in her favour under the said policies.FINDINGS : The insurer informed that the DLA was operated for Pneumo Thorax asper the CR No. 3965 dated 3.11.05. The DLA himself informed the doctor about acutepain in chest and breathlessness and he remained in the hospital from 3.11.05 to21.11.05. In view of the above report it is clear that the DLA suffered from heartproblem before the date of proposal and it was also in the knowledge of the DLA whichhe did not disclose it in the proposal form. Had he disclosed it in the proposal form, thecase would have been underwritten after due consultation with the DMR. Hence, firstpart of section 45 of Insurance Act, 1938 became operative and the claim wasaccordingly repudiated.DECISION : Held that in view of the clarifications given by the insurer andcorroborative evidence on record, the repudiation of the claim by the insurer was inorder and the same was upheld. The complaint was dismissed.Chandigarh Ombudsman CentreCase No. : HDFC/397/Mumbai/Hissar/21/07SukhjivVsHDFC Standard Life Insurance Co. Ltd.Order dated: 29.3.07FACTS : Ms. Sukhjiv’s husband Late Shri Rohit Joshi had purchased a policy bearingno. 10403372 with DOC 30.10.05 for SA of Rs. 5 lakhs under Term Assurance Policy.Her husband expired on 20.5.06 due to sudden heart problem. The insurer wronglyrepudiated the claim considering the cause of death as suicide. She stated that shehas no source of livelihood and total liability on her old parents who also have nosource of income. The PMR did not mention that traces of poison were found in thebody. The cause of death was shown as cardio pulmonary oedema. She contended thatthis was not a case of suicide but natural death.FINDINGS : The insurer informed vide letter dated 6.3.07 that the LA Shri Rohit Joshiwas issued a Term Assurance Policy on 24.10.05. The LA expired on 20.5.06 after thepolicy had been in force for less than 7 months. The LA was 34 years of age andprobably this was the only insurance policy he had. The investigations revealed that LAhad committed suicide and his body was found near a field. The father of LA hadreported to the Police that LA had committed suicide and that his body was found neara field, away from the residence. The death report by the police also stated that the LAmay have committed suicide by consuming poison. The Chemical Analysis Report

states that no common poison was found in the samples checked. The Medical Officeropined that it may be due to the fact that more than 6 hours had elapsed after theingestion of the poison. It was stated that as LA had committed suicide within one yearof the date of issue of the policy, the complainant’s claim stood excluded under clause8 of the policy. Hence the claim was invalidated vide letter dated 11.1.07. The insurerfurther quoted decision of the National Consumer Disputes Redressal Commission inLaxman Prasad Patel Vs LIC & others, in support of company’s stand that thestatement to the Police by the father of their son having committed suicide is reliableevidence in law. Copy of the National Commission’s Order was enclosed for perusal. Itwas submitted that the company had repudiated the claim bonafide and on relevantconsiderations. On a query whether the father of the deceased was present at the timeof death, the reply was in the negative. On a query whether any suicide note wasfound, the reply was in the negative. On a query whether the chemical analysis reportmentioned traces of poison in the body, the insurer mentioned that the PMR andchemical analysis were done after six hours when the poison contents could have beenuntraceable. The contention of the insurer that the statement of the father should bethe basis for DLA having committed suicide was not in order, as it could be an opinionexpressed on the spur of the moment when he was confronted by a sudden shock. ThePMR and chemical analysis report do not substantiate the suicide theory and a panel ofdoctors has given a report which negates the view that the cause of death was due toconsumption of poison.DECISION : Held that the sum assured of Rs. 5 lakh along with accrued bonus if anybe paid to the nominee/claimant.Chennai Ombudsman CentreCase No. : IO (CHN)/21.03.2279Smt. N. SaraswathiVsLife Insurance Corporation of IndiaAward Dated : 06.11.2006Sri. M.Thandapani (Decd.) took two life Insurance Policies- 741833331 & 741833332from LIC of India, Madurai city Branch-II under Madurai Division by submittingproposals on 20.10.2000. The policies were issued with Date of Commencement of riskcover as 28.07.2000, for Rs. 50,000/- Sum Assured each. Sri. M.Thandapani who wasworking as a Trade Man with the state owned Transport Corporation opted to pay hispremiums by authorizing his employer to deduct it from his salary. As policies underthis scheme were serviced by LIC Thirunagar Branch of Madurai, the employer remittedpremiums to that Branch up to due September 2002 with three gaps. The life assureddied on 21.12.2002. The Complainant and nominee Smt. T.Dhanalakshmi claimed thedeath benefits under both the policies. The insurer rejected her claim on the plea thatthe life assured had taken treatment for Cancer from 14.01.2000 to 17.02.2000 andwhich information was suppressed in the proposals dated 20.10.2000.The complainant stated that she was not aware of these policies during her husband’slifetime. She agreed that her husband used to take leave often and for the reason ofbeing sick. The Ombudsman asked her whether she was aware of the eye operationwhich her husband had undergone for which she replied that she was not aware. Sheadded that as they had no children her husband may not have told her of his illness.The representative of the Insurer stated in the hearing that the policies were in lapsedcondition. According to the Claim Form ‘B’ given by Arvind Hospital, the cause of death

was mentioned as ‘Malignancy’ and the Life Assured was taking treatment since16.06.1999 i.e., well before the date of Proposal. As per the reports received fromArvind Hospital, the Life Assured was suffering from Secondary Metastasis to left Orbitand had undergone lateral orbitotomy on 06.08.1999 and also received 6 cycles ofChemotherapy. The life assured had also taken Radiation treatment for Cancer atMeenakshi Mission Hospital and Research Centre, Madurai from 04.01.2000 to17.02.2000.There is nexus between the cause of death and illness suppressed. The Insurer hasproved with clinching evidence that the life assured had furnished wrong informationabout his state of health in the proposal and suppressed that he was suffering fromCancer even before proposing for insurance. By withholding information that was verymaterial, the life assured has misguided the insurer in wrongly issuing the policies.The Complaint was dismissed.Chennai Ombudsman CentreCase No. : IO(CHN)/21.04.2278/2006-07Smt.R.MasilaVsLife Insurance Corporation of IndiaAward Dated : 06.11.06Sri.M.Rajangam had taken an Endowment policy bearing no. 743811003 forRs.100,000/- and nominated his wife Smt. R.Masila as nominee. He died on03.07.2005. The Insurer denied the death claim payments on the ground that theassured had suppressed the material facts of his suffering from Urolithiasis with rightureteric vesical junction calculus with ARF, his ischemic heart disease, his consultationwith the doctor and the treatment availed three years prior to his proposing forinsurance and hence the policy was declared void and hence the complaint preferredwith this Forum by the nominee Smt. R.Masila.On 15.09.2006, a personal hearing of both the parties was held. The complainant wasnot present. Her letter was read out. In that she said that her husband had taken thepolicy for income-tax purpose. As the Madurai office had rejected her claim she wantedthe Ombudsman to mediate and get her the claim proceeds. The insurer stated that thedeceased life assured took a policy in February 2005 by submitting a proposal on25.02.2005. As the claim was a very early claim, death having taken place within 4months and 8 days of taking the policy they got a ‘Claim Investigation’ done by one oftheir Officials. The Official had noted in his report that the life assured had takentreatment at Meenakshi Mission Hospital and Research Hospital, Madurai. Whereas thelife assured in his proposal had not mentioned his illnesses or that he had takentreatment in the hospital.On a careful study of the representation of the complainant and the case presented bythe insurer along with the Forms and certificates of treatment taken by the life assured,it was proved that the life assured had been hospitalized and he was treated for hisCalculi and also advised about his heart condition in early 2002 itself. However he hadnot disclosed his correct health condition in his proposal dated 25.02.2005. Bysuppressing information that was very essential for the Insurer to assess his risk, thelife assured has misled the Insurer in issuing the policy at normal rates. Therefore therepudiation of the complaint’s claim for the assured sum and its ancillary benefits by

the Insurer on the ground that the insured had withheld material information regardinghis health is sustainable.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.04.2268Smt. S.BalamaniVsLife Insurance Corporation of IndiaAward Dated : 08.11.2006.Sri. P.Sakthivel took an Endowment policy bearing No.742683462 for Rs.100000/- fromLIC of India, Dindigul Branch (under Madurai Division). The date of commencementwas 20.03.2001 with the half-yearly premium being Rs.3969/-. On 20.11.2004 herevived the policy (which was lapsed due to non-payment of the premium due in March2004) on the strength of a “Personal Statement of Health” which was dated 10.11.2004.The life assured died on 16.01.2005 and Smt.S.Balamani, wife of the LA claimed thedeath benefit. The Insurer repudiated the claim on the ground that the LA had notdisclosed the fact, at the time of revival that he had suffered from Comminuted LateralCondyle Fracture, that he was a hypertensive and that he had taken treatment at CMC,Vellore for Inferior Wall Myocardial Infarction.In the hearing the complainant Smt. S.Balamani, said that her husband had died ofheart attack. She added that he was not well for 6 months before his death. She alsoinformed that he had met with an accident three years back for which he was operatedthrice. She replied that her husband had availed medical leave during 2003& 2004 ondoctor’s advice and to help during their daughter’s delivery. The Insurer informed thatthey had repudiated the claim as the life assured had not disclosed the treatment takenin various spells at different hospitals, during the pre-revival period, in his “PersonalStatement of Health” dated 10.11.2004. However they had offered to pay Rs. 37400/-which was the paid-up value and the bonus thereon.Keeping in mind the health background of the insured as evidenced from records, thefalse answers to question 2a),2b) and 2c) and question 4 of the “Personal Statement ofHealth” signed on 10.11.2004 was a clear case of suppression of “material facts” andthe repudiation was justified. There is also a nexus between the cause of death and theillness suppressed. Therefore the decision of LIC of India to pay Rs.37400/- as thepaid-up value with the accrued bonus is valid.Chennai Ombudsman CentreCase No. : IO (CHN)/21.04.2307.Sri.M.SelvarajVsLife Insurance Corporation of IndiaAward Dated : 14.11.2006Sri. S.Inbaraj, submitted a proposal to LIC of India, Periyakulam Branch under MaduraiDivision, to get life insurance cover.The policy numbered, 742820583, was for a sum assured of Rs.50000/-, under theEndowment Plan with a term of 16 years. Premiums were deducted from his salary andpaid to LIC by his employer. As he was not married he had nominated his father. Thelife assured died on 15.03.2005. Sri M.Selvaraj, father of the life assured claimed thebenefit under the above policy. The Insurer repudiated the claim stating that the life

assured had withheld correct information regarding his health at the time of effectingthe assurance with them.In the hearing as the complainant was absent the Representative of the Insurer wasasked to present his case. The Representative informed that the life assured hadavailed two spells of medical leave. Whereas the nominee had written in his letter thatthe medical leave was availed for house construction the Insurer had proof that at thetime of taking leave the life assured was undergoing treatment in Christian FellowshipHospital, Oddanchatram. The Representative added that they had repudiated the claimbecause the proposer while proposing for insurance had not disclosed material factsregarding his ill-health, the treatment taken and the particulars of medical leaveavailed by him.On going through the documents it is evident that the life assured was admitted inChristian Fellowship hospital for severe anemia, diarrhea and Urinary Tract Infection.This period of hospitalization coincides with the period of medical leave availed andthe illnesses of the life assured tallies with those mentioned in the medical certificate.The doctor with Christian Fellowship Hospital, Oddanchatram, who had signed theDischarge Summary when the life assured got discharged on 12.11.2002 (Date ofadmission into the hospital is 07.11.2002), had diagnosed the life assured as HIV +ve(by ELISA test) with severe anemia and Urinary Tract Infection.Thus a careful and dispassionate study of all the evidences available in the case fileproved beyond any shred of doubt that there was a clear and deliberate suppression ofvital information relating to a very serious ailment the assured suffered from in the preproposalperiod. The decision of the insurer to deny the claim under the policy is heldto factually sustainable and this Forum upholds the same.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.03.2279Smt. N.SaraswathiVsLife Insurance Corporation of IndiaAward Dated : 06.11.2006Sri. A.K.Natarajan, the deceased life assured was employed as Head Constable inChithode Police Station. He signed a proposal under non-medical scheme on23.04.2004, with LIC of India, Erode North branch of Coimbatore Division, to get a lifecover for Rs.75000/-. The policy with number 762207711 was under Jeevan Saral witha 12 year term. The life assured died on 11.04.2005 due to “Pancreatitis with MetabolicEncephalopathy”. Smt. N. Saraswathi, as the Appointee for the minor nominee-MasterN.Sathish Kumar, claimed the money from the Insurer. The Insurer repudiated theclaim under the above policy as the life assured had given incorrect answers toquestion numbers 11a to 11e and 11i in the proposal dated 23.04.2004.In the hearing on 09.10.2006 the complainant replied that her husband was in goodhealth and he availed leave to look after his children whenever they fell sick. Also hisparents were ailing and he used to take leave to take care of them. The Insurer statedthat the deceased life assured had availed 31 days of medical leave prior to the date ofthe proposal for treatment of “Acid Peptic disease” and they had obtained medicalopinion from their Divisional Medical Referee, who opined that “it is likely that the lifeassured had a medical disorder. The Insurer had repudiated the claim for notdisclosing the medical leave availed by the life assured before the date of theproposal.

On perusing the documents it is observed that the Insurer was not able to get any validproof for the life assured having taken treatment for Acid Peptic Disease. According tothe complainant in her appeal dated 07.06.2006 her husband used to take medicalleave to spend time with his children during vacation time. As no other leave would besanctioned to police personnel he had to resort to availing medical leave. This seemsto be in order as the medical certificates available in the file are for the period from13.05.2003 to 12.06.2003 and this period falls during school summer vacation. There isno prescription for medicines from a doctor for having treated the life assured tosubstantiate the Insurer’s claim that the life assured was not keeping good health priorto the date of the proposal. It is incumbent on the Insurer to exercise all care to satisfywith clinching documentary evidence that material facts were fraudulently suppressedto avoid a Contract of Insurance.The complaint is allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.01.2261Smt. K.UmamageswariVsLife Insurance Corporation of IndiaAward Dated 06.11.2006Sri. G.Kirubanithi submitted a proposal on 28.10.2003 to LIC of India, Branch-17 underChennai Division-II and obtained a policy, numbered 716996580, for sum assured ofRs.35000/-. As the premiums for the policy had to be paid from his salary the policy filewas transferred to GSSS department of Chennai Division-I. The life assured died on06.11.2004 at Apollo Hospitals, Chennai due to Kidney failure. Smt.K.Uma Mageswari,the nominee under the policy submitted her claim to the Insurer. The Insurer rejectedher claim as the life assured had withheld correct information regarding his health atthe time of proposing for insurance.In the hearing on 20.10.2006 the complainant, Smt.K.Uma Mageswari, stated that herhusband used to go to office regularly. She admitted that her husband had Diabetesand that she used to give him insulin injection. Her husband took treatment forDiabetes from Dr.Sekar. In October 2004 he took treatment in Sri RamachandraMedical Centre as he had exceeded his employer’s reimbursement limit for treatment atApollo Hospitals. The Insurer stated that the life assured had failed to disclose thedetails of Diabetes Mellitus, Nephropathy, Hypertension and Ischemic Heart Diseasewith L.V. Dysfunction in the proposal. Dr. K.R.Sekar had also confirmed the existenceof Diabetes Mellitus, High BP, Hypothyroidism and Diabetes Nephropathy for 3 yearsprior to life assured’s death. The doctor had treated the life assured for the same. TheInsurer said that had the life assured disclosed his illness, their underwriting decisionwould have been different.Considering the health background of the insured as discussed above, the falseanswers to question 11a),11b),11c) 11e) and 11i) in the proposal signed on 28.10.2003was a clear case of suppression of “material facts” and the repudiation was justified.There is also a nexus between the cause of death and the illness suppressed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.01.2285Sri. A.DhananjayanVsLife Insurance Corporation of India

Award Dated : 28.11.2006Ms.D.Kadambari, when employed in M/s.Slash Support India Pvt. Ltd, obtained ainsurance Policy from LIC of India, Branch- XXI of Chennai D.O.-I. She signed aproposal on 11.06.2004 for the same. The policy numbered 713991464 had SumAssured as Rs.2.5 lakhs. The life assured died on 22.02.2005 at Apollo Hospitals,Chennai due to 50% burns and Septicemia. Sri.A.Dhananjayan, the nominee under thepolicy submitted his claim to the Insurer. The Insurer rejected the claim as the lifeassured had suffered from Schizo-effective disorder (mood disorder) and had beenhospitalized for treating the same. She had not disclosed any of these in her proposaldated 11.06.2004.In the hearing on 20.10.2006 the complainant, admitted that his daughter washospitalized and had taken treatment as she had complaints of sleeplessness. He saidthat his daughter was highly qualified and since she was in the software professionthere was some disturbance in the sleeping pattern. When it was pointed out that hisdaughter had not revealed the treatment she had undergone, in the proposal, he saidthat since it was an ordinary treatment, she might not have felt it necessary to mention.The insurer stated that the life assured died within 8 months and 10 days of taking thepolicy. The life assured had suffered from Schizo effective disorder (mood disorder)before proposing for insurance on 11.06.2004. The relevant details were not disclosedin the proposal form. Had they been disclosed, their underwriting decision would havebeen different.On going through the documents it emerges that the life assured had suffered from anillness which is not a passing ailment like cold, cough, fever etc. which could haveescaped her memory at the time of proposing for insurance. So her father’s contentionthat it was an ordinary treatment which she might not have felt necessary to mention inthe proposal is difficult to accept. Even though there is no nexus between the cause ofdeath and illness suppressed the Insurer has proved with clinching medical evidencethat there was material suppression of facts and by suppressing these importantinformation the life assured had deprived the Insurer of a fair chance of havingevaluated the risk correctly.Chennai Ombudsman CentreCase No. : IO (CHN)/21.003.2264.Smt.B.ManimekalaVsTATA AIG Life Insurance Co. Ltd.Award Dated : 14.12.2006Sri G.Kameshwaran applied to Tata AIG Life Insurance Co. for a Life Line plan on22.12.2005. According to the policy issued on 23.12.2005 the Life Assured was entitledto get the refund of premiums on surviving the term and 2 lakhs on death during theterm of the policy (4 Lakhs in case of death by accident. Sri G.Kameshwaran died on03.04.2006 at Apollo Hospitals due to Acute Lymphoblastic Leukemia (ALL) withrelapse with Refractory disease. His mother preferred the claim with the Insurer. TheInsurer rejected her claim on the grounds that the life assured had not revealed in theapplication for insurance dated 22.12.2005 that he had been under treatment for ALLsince 2000 and that he underwent Orchidectomy for relapse in 2003.In the hearing, on 17.10.2006 the representative of the complainant stated that his sonviz. the life assured was working as a Software Engineer at Chennai after completinghis B.E. His son approached. Citi Financial for a loan to buy a Car. Since Citi Financialwas an agent of Tata AIG they had offered insurance to his son. His son signed the

application for insurance on 22.12.2005. His son had not disclosed his past illness inthe application because he was in normal health when he took the policy. The insurerstated that the life assured had not disclosed in his application for insurance dated22.12.2005 the details of his treatment for Acute Lymphoblastic Leukemia since 2000and undergoing Orchidectomy in 2003 for relapse. The assured was a SoftwareEngineer and a highly educated person and it was not acceptable that he has justsigned the proposal without going through the contents in the proposal. Whenquestioned about Citi Financial and the nature of insurance policy sold by them, heclarified that it was not a group policy or a collateral security policy.It is therefore clear that the life assured was affected by a serious disease; which couldbe controlled but not cured. It is therefore difficult to accept the argument of therepresentative of the complainant that the life assured was normal on the day hesigned the application. Perhaps the life assured had no fraudulent intention when heapplied for insurance as it was taken at Citi Financials, the financial company he hadapproached to advance him funds to buy a car. However there is clear medicalevidence to show that he was suffering from Leukemia well before signing theapplication for insurance.Chennai Ombudsman CentreCase No. : IO (CHN)/21.05.2353Smt. D.AnguVsLife Insurance Corporation of IndiaAward Dated : 22.12.2006Sri. S. Duraisamy signed a proposal for the Insurance Policy on 27.07.2003, andsubmitted it to LIC of India, Salem North Branch. He was issued a policy bearingnumber 701356661 for a SA Rs.30,000/- under Endowment Plan. Sri. S. Duraisamydied at his residence on 02.05.2004, due to Chest Pain. Smt. D. Angu, his wife andnominee under the policy preferred her claim with the Insurer. The Insurer rejected herclaim on the grounds that the life assured had suppressed the Major Road TrafficAccident met by him in 1995, in which he had sustained severe injuries to his left armand leg.In the hearing on 15.11.2006, Smt. D. Angu was not present and her representationwas read out. In that letter, she had stated that her husband Mr. Duraisamy had metwith an accident on 23.06.1995. Smt. Angu also stated in her letter that her husbandwas going to his office from 1995 to 2004 regularly and he was healthy. The Insurerstated that as death occurred within 9 months from the date of commencement of thepolicy they had arranged for an investigation and by that they learnt that during theyear 1995 the life assured had met with a major road accident. However, it was notdisclosed by the life assured at the time of proposal.The Insurer had repudiated the claim merely because the life assured had notrevealed the accident that had occurred 8 years ago as on the date of the proposal.The Insurer had not produced any evidence to conclusively prove that the accident wascausing the life assured medical discomfort and had hastened his death. The Insurerhad not produced any prescription to show that the medicines taken for the injuriescaused in the accident had reduced the normal life span of the life assured. Thus therewas no justification for the insurer to repudiate the claim. Thus their decision torepudiate the claim does not stand the text of ethical and legal scrutiny and the sameis untenable in law and as well on facts.The complaint was allowed.

Chennai Ombudsman CentreCase No. : IO (CHN)/21.003.2430Smt.M. NavamaniVsTATA AIG Life Insurance Co. Ltd.Award Dated : 22.12.2006Sri. M. Murugesan signed an application on 06.08.2003 to obtain a Life InsurancePolicy-Assure 20 years Security and Growth Plan from Tata AIG Life Insurance Co. Thesum assured under the plan was Rs.1 lakh and he paid an amount of Rs.1852/-. TheInsurance Company issued a policy on 10.10.2003 with quarterly premium as Rs.1928/-. Sri. M. Murugesan died on 27.07.2004. Smt. M. Navamani, the nominee under thepolicy, preferred the claim with the Insurer. The Insurer repudiated the claim on theground that the life assured had been hospitalized and diagnosed to have Carcinoma ofBladder in Sept. 2003, which was before the policy issue date of 10 th Oct. 2003.In the hearing the Insurer stated that though the life assured’s application for insurancewas dated 06.08.2003, the premium was paid on 28.08.2003. The application wasreceived by them on 29.08.2003. Balance of premium was called for on 30.08.2003.The balance of premium was received on 01.10.2003 and the policy was issued on10.10.2003. The life assured was hospitalized on 19.09.2003. The assured had noticedblood in urine 2 months back viz. July 2003. The life assured died on 27.07.2004. Thelife assured had not given correct answers for Question No.4 (h) viz. urine abnormality.After submission of the application and before acceptance of the policy there waschange in the health of the life assured which he had not informed to the insurer.A perusal of relevant documents reveal that policy issue was delayed due to nonreceiptof extra premium charged by them for the life assured’s occupation (Whereas inthe application itself the life assured had mentioned his occupation). Also there is noclear guidelines for LA to inform the insurer changes in health condition, before policyis issued. The life assured was only a mason (application is in English and he hadsigned in Tamil). The insurer had not obtained medical evidence to substantiate theirstand. However, the fact cannot be ignored that the assured had not mentioned thebladder disorder that he was suffering or the diagnostics test that he had undergoneabout which there are specific questions in the application for insurance. As such, thisForum decides that an amount equal to 20% of basis sum under the policy i.e. anamount of Rs.20,000/- be made available to the complainant as full and final settlementof the claim under the policy on an ex-gratia basis.The complaint was partly allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.02.2306Sri. Munusamy ReddiarVsLife Insurance Corporation of IndiaAward Dated : 20.12.2006Smt. M. Sarasammal obtained policy bearing number 716 240 071 under T-133 (JeevanMitra-Triple Cover- According to this plan the maturity benefit is basic Sum Assuredwith Bonus and the death benefit is three times the Sum Assured plus Bonus) for a sumassured of Rs.25000/- with a monthly premium of Rs.123/- from LIC of India,Villivakkam Branch under Chennai DO-II by submitting a proposal on 13.06.2000. Inthe proposal she had mentioned that she was working as an helper to mason. Smt. M.Sarasammal died on 31.05.2004. Her husband and the nominee Sri Munusamy Reddiar

preferred a claim with the Insurer. The Insurer settled basic sum assured and theaccrued bonus, as the life assured was not eligible for this high risk plan (T-133). Sri.Munusamy Reddiar’s appeal to the Zonal Office of the Insurer, fetched him enhancedSum Assured for the extra premium paid for T-133.In the hearing on 14.11.2006 the representative of the complainant stated that theagent, who had sold this policy to his mother, had sold it to nearly 13 or 14 peoplewhich included a few ladies as well. He argued that if it was the mistake of the agent,then the office also had allowed that plan to his mother. As there was no suppressionof any material fact, the non-payment of full amount of claim was not correct. TheInsurer stated that in underwriting the female lives were classified into three categoriesbased on their source of income and level of economic independence. In thatclassification, the Life Assured was classified under category III and this plan could nothave been given to her. It was a genuine mistake. He said that the parties to theagreement were not entitled to get the benefits of apparent mistakes.A scrutiny of the papers reveals that the policy was in force, the life assured had notsuppressed her occupation, she had paid 48 monthly premiums andThe Insurer has not brought any evidence to show that the life assured had willfullysuppressed material facts with a fraudulent intention to gain out of the contract.The Complaint is allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.08.2384Smt. E.SelvamVsLife Insurance Corporation of IndiaAward Dated : 22.12.2006Sri A.Elayappan submitted a proposal on 12.03.2004 to LIC of India, KallakurichiBranch under Vellore Division to obtain the policy bearing number 733457151 underTable –143 (Bima Nivesh Triple Cover Plan) for Rs.3 Lakhs (Death Benefit would be 9Lakhs) after paying single premium of Rs.284034/-. Sri A.Elayappan died on20.04.2004, due to heart attack. Smt.E.Selvam, the nominee under the policy preferredthe claim with the Insurer. The Insurer rejected the claim on the grounds that the lifeassured had withheld correct information regarding his health at the time of effectingthe assurance. Smt.E.Selvam, represented to the Zonal Manager of the Insurer, whooffered Rs.3 Lakhs as ex-gratia.In the hearing on 28.11.2006 Sri E. Jeyakarthic, son of the complainant, said his fatherSri A.Elayappan had complained of chest pain and initially thought that it was due togastric problem. Since the pain grew, he had called him and he in turn instructed himto come to Chennai for treatment. When his father was about to start to Chennai hecollapsed in the toilet due to heart attack. His father had paid a Single Premium ofRs.284034/- for the Bima Nivesh Triple Cover plan (Table 143) and the Date ofcommencement of the policy was 12.03.2004. His father died due to massive heartattack on 20.04.2004. His father had undergone Master Check up twice – once in theyear 2001 at Vijaya Hospitals, Chennai and again in the year 2003 at Apollo Hospitals,Chennai. On 28 th April 2005 LIC had repudiated the claim in full including the lump sumpremium paid and the reasons stated were his father had suffered from CervicalSpondylosis and Pruritus with old fracture of right clavicle and the information hadbeen withheld in the proposal. After a painful follow up for 283 days with personalvisits, LIC sent a communication that the decision has been reconsidered and prepared

to pay an ex-gratia of 3 Lakhs. In the hearing the Insurer stated that it was a TripleCover Policy for Rs.3 Lakhs Sum Assured. Rs.2,84,034/- had been received as Singlepremium. The policy had run for 1 month and few days. On going through the previousmedical check ups, they found that the assured had health problem prior to proposingfor this policy. They had carefully examined the facts of the case before deciding onex-gratia payment of Rs.3 Lakhs.Beyond the two Health Check-up reports (which were given by the claimant herself) theinsurer had no medical evidence to conclusively prove that the assured was ailing fromsome serious ailment for which he undertook treatment and further that the ailment wasof such a serious nature as to affect their underwriting decision. The insurer failed toprove with any clear-cut evidence that the assured suppressed material information,with a fraudulent intention.The Complaint is allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.08.2357Sri.T.V.RenuVsLife Insurance Corporation of IndiaAward Dated : 26.12.2006Smt.D.Aiyammal submitted three proposals in August 2004 to LIC of India CheyyarBranch under Vellore Division to obtain three policies under ‘Bima Plus’ Plan. Theamount payable as death benefits under the plan will be the bid value of thepolicyholder’s unit account as on the date of death together with an amount equal tofull SA or a portion depending on duration run by the policy. The life assured died on30.07.2005 that is within 11 months and 18 days. Sri T.V.Renu, as the Appointee forthe minor nominee approached the Insurer for death claim. The Insurer paid the bidvalue of the policyholder’s unit account as on the date of death, but rejected to pay the60% of Sum Assured, on the grounds that the life assured had withheld correctinformation regarding her health at the time of effecting insurance.In the hearing on 28.11.2006 as the representative of the complainant was not presentfor the hearing one of the officials read out the letter dated 02.11.2006. He had statedin his letter that the life assured had taken 3 Bima Plus Single Premium Policies withLife Cover. She died on 30.7.2005 within 11 months after the commencement of thepolicy. The complainant received cheques for the Market Value of the shares under allthe 3 policies and asked for clarification pertaining to the policy which states that incase of Death of the life assured, the nominee/heirs would get 60% of the Sum assuredand the Bid value of the policy holder’s unit account as on the date of death. Theinsurer stated that in this policy one portion of the premium covered life and rest of theamount was invested in UNIT linked business which would be invested in the sharemarket and the benefit returned to the policy holders. However the Insurer stated thatthe Life assured submitted the proposal forms during the month of August 04 and inthose forms the Life Assured had not mentioned about her treatment for AIDS. Therepresentative of the complainant had stated in the claim form that the claimant dieddue to stomach pain but after investigation they had found out that the life assured hadbeen diagnosed to be HIV positive prior to the proposal.A careful consideration and scrutiny of all the available evidence, establish that theInsurer had beyond doubt proved that the assured was indeed suffering from AIDS at

the time of taking the policies. In the result, the complaint fails and the complaint isthus disposed off on merits as aforesaid.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.08.2369Smt.S.SarathaVsLife Insurance Corporation of IndiaAward Dated : 29.12.2006Sri N. Singaravadivelu took a Jeevan Suraksha Policy (Pension Policy) from LIC ofIndia, Panruti Branch, under Vellore Division, by submitting a proposal for theinsurance on 03.03.2001. Sri N. Singaravadivelu died on 19.09.2001. Smt. S. Saratha,his wife and the nominee, preferred her claim with the Insurer on 20.07.2003. TheInsurer rejected the claim on the grounds that the life assured had withheld materialinformation regarding his health at the time of effecting the insurance.In the hearing on 28.11.2006, the complainant stated that her husband was quitehealthy. The last posting had been stressful and he used to complain of tiredness andheadache. He used to bring files home. When questioned as to why they preferred theclaim very late, she said that their only son was trying to get employment in TNEB oncompassionate grounds. Dr.Nayab who was a good friend of her husband had givenClaim Form B which the insurer had lost. Again the Insurer had obtained a Claim formB from the same Doctor. The information given in the two forms were contradictory.The insurer stated that the risk under the Jeevan Suraksha policy with life covercommenced on 09.03.2001 under medical scheme with death benefit payable as 50%of the targeted pension. The policy had run for hardly 6 months. As per the Claim FormB given by Dr.Nayab he had treated the life assured since 1999-2001 for Hypertensionand Diabetes and this he confirmed vide his letter dated 07.07.2004.It is evident that the life assured was diabetic and hypertensive before proposing.However the insurer had relied on mere claim forms to repudiate the claim. Equity andnatural justice call for consideration of the case keeping both the parties in mind and,the Insurer was, therefore, directed to pay the complainant an amount of Rs. 15,000/-under the policy in full and final settlement of the claim.The complaint was partly allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.08.2385Smt.T.AmbikaVsLife Insurance Corporation of IndiaAward Dated : 11.01.2007Smt. Kolanjiammal submitted a proposal on 31.03.93 to LIC of India, VriddachalamBranch to Policy bearing number 730214360. The policy was for a sum assured ofRs.25000/- with a quarterly premium of Rs.385/- . Age proof submitted by her washoroscope. Smt. P. Kolanjiammal died on 18.08.2005. Smt. Ambika, the nominee underthe policy submitted her claim papers to the Insurer. The Insurer repudiated the claimon the grounds that the life assured had with held material information regarding herage at the time of effecting the assurance with them.

In the hearing the representative of the complainant, stated that his brother had takena policy on the life of their mother and nominated his wife viz. Smt.T.Ambika. Hisbrother died in an accident in March 2005 and subsequently his mother also died inAugust 2005. He was told that the claim under the policy was repudiated since therewas understatement of age of his mother in the proposal. He said that probably bymistake there might be some difference. The Insurer stated that they came to knowthat Smt.Kolanjiammal was the mother of the agent Sri.Thirumoorthy at the time ofprocessing the claim. Sri.Thirumoorthy had stated the age of his mother (nominee) inthe proposal of his own life on the same date viz.31.03.1993 as “60” years and in theproposal on his mother’s life he has falsely stated her age as 48 years. In the DeathCertificate her age was mentioned as 73 (at the time of death). Had the correct agebeen mentioned, they would not have considered issuing an Endowment policy on herlife. The policy was revived on 3 occasions. In all the occasions Sri.Thirumoorthy hadwitnessed the declarations fraudulently without revealing the correct age or hisrelationship to the life assured.The relevant points are that 12 years premiums were received, the agent whocommitted this error is dead and the Policy was issued after a medical examination.The life assured can not be absolved of her responsibility as she has signed theproposal form (Here, it is worthwhile to note the general principle that a party of fullage and understanding is normally bound by his signature to a document whether hereads it, understands it or not.). Equity and natural justice call for consideration of thecase keeping both the parties in mind and that both are taken care equitably and, assuch, this forum decides that the claim be considered on an ex-gratia basis and theInsurer is, therefore, directed to pay the complainant an amount of Rs. 15,000/- underthe policy in full and final settlement of the claim.The complaint was partly allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.08.2338Smt.R.KalvikkarasiVsLife Insurance Corporation of IndiaAward Dated : 12.01.2007Sri. R. Raju submitted a proposal on 8.03.2000 to LIC of India, Tirukoilur Branch underVellore Division and obtained a policy bearing number 731259048 for a Sum Assuredof Rs.50000/- under Jeevan Mitra Triple Cover. He paid the quarterly premium amountof Rs.723/-, till due Jan 2003. There after the policy lapsed due to non-payment ofpremiums. Sri. R. Raju revived the policy on 13.12.2003 by submitting a “PersonalStatement of Good Health” and a Medical Report from a doctor in the pane1 of theInsurer. Sri. R. Raju died due to HIV/pleural effusion (RT) /Respiratory Failure, on31.03.2004 at Government Hospital of Thoracic Medicine Tambaram, Chennai. Smt. R.Kalvikkarassi his wife and nominee preferred her claim for the full benefits with theInsurer. The Insurer rejected her claim for full amount on the grounds that the lifeassured had revived the policy on 13.12.2003, by misrepresenting the real state of hishealth.In the hearing on 15.11.2006 the complainant stated that her husband took a policy in2000. He was healthy at the time of taking policy and he was paying premiumsregularly. In the year 2003 he revived the policy after taking a loan. When questionedas to when he was first detected as HIV positive, she admitted that he was diagnosedas HIV + in the year 2001. The Insurer stated that the life assured had taken the policy

in January 2000. The policy was revived on 13.12.2003 on the strength of a“Declaration of Good Health” dated 13.12.2003 and with 3 quarterly premiums. Therevival was void since he was detected to be HIV positive in January 2001 itself. Theyhave obtained a letter from the Tambaram Hospital regarding the period of in-patienttreatment undergone by the life assured in the hospital.The Insurer had obtained clinching evidence to prove that the life assured was affectedby HIV and aware of the fact in the year 2001 itself. The declaration made by the lifeassured on 13.12.2003 regarding his health was incorrect. There was also a nexusbetween the cause of death and the illness suppressed.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.08.2366Smt. DhanamVsLife Insurance Corporation of IndiaAward Dated : 18.01.2007Sri. C.Settu submitted a proposal on 23.01.1999 to LIC of India, Tiruvanamalai Branchunder Vellore Division and obtained a policy bearing number 731118021 for a SumAssured of Rs.59000/- under Endowment Plan. The policy lapsed due to non-paymentof premiums after July 2000. Sri. C.Settu revived the policy on 20.05.2003 bysubmitting a “Personal Statement of Good Health” of even date and by paying therevival amount by cheque. The cheque was dishonored and the policy lapsed.Subsequently he revived the policy again by submitting a “Personal Statement of GoodHealth” on 18.07.2003. Sri. C.Settu died due to Myocardial Infarction on 05.09.2003.Smt. Dhanam, his wife and nominee preferred her claim for the death benefit with theInsurer. The Insurer, rejected her claim on the grounds that the life assured hadwithheld correct information regarding his health at the time of revival.In the hearing on 28.11.2006 the complainant stated that her husband was quitehealthy. Sometimes he used to complain of chest pain and used to take tablets. Oneday after he came back from work he complained of chest pain and died. Whenquestioned whether they knew Dr.Ramana Rao of Grace and Compassion Hospital atTiruvannamalai, she said that she knew the hospital but not the Doctor. The insurerstated that the policy lapsed and was revived on 18.07.2003 on the strength ofDeclaration of Good Health of even date. The cheque paid towards renewal washowever dishonoured for the reason “insufficient funds”. The premium was paid in cashthe second time along with DGH dated 18.07.2003. The life assured had takentreatment on 15.07.2003 at Grace and Compassion Hospital which he had notmentioned in the DGH dated 18.07.2003.Therefore the Insurer has established beyond doubt that on 18.07.2003 the life assuredhad furnished incorrect information in his “Personal Statement of Health”. The lifeassured was very well aware of the gravity of his health condition as the doctors inGrace & Compassion Hospital had advised him to avail treatment at JIPMER,Pondicherry as “his condition was not satisfactory”.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.07.2311Smt. R.Mariammal

VsLife Insurance Corporation of IndiaAward Dated : 18.01.2007Sri M.Ramar Pillai submitted a proposal on 19.02.1998 to LIC of India, SankarankoilBranch under Tirunelveli Division and obtained a policy bearing number 320577169, fora Sum Assured of Rs.100000/-. He paid the premiums due till August 2001, after whichhe could not pay two dues. He revived the policy on 07.12.2002 under the Insurer’s‘Special Revival Campaign. Sri M.Ramar Pillai died on 06.12.2005. Smt.R.Mariammal,his wife and nominee under the policy preferred the claim with the Insurer. The Insurerrejected the claim on the grounds that the life assured had withheld correct informationregarding his health in the “Personal Statement of Health” submitted at the time ofreviving the policy on 07.12.2002.In the hearing on 05.12.2006 the complainant mentioned that Sri M.Ramar Pillai wasquite healthy when he had first taken the policy. In the year 2000, after an accident hewas diagnosed as diabetic. His leg was amputated. He applied to the Insurer for hisdisability claim on 25.10.2000. He visited the LIC office and revived the policy in 2002.In 2005 his other leg too was amputated, and this was also informed to the Insurer.The Insurer stated that the policy was in a lapsed condition from February 2002 andthe policy was considered for revival based on the life assured’s declaration of goodhealth. However the life assured had undergone treatment at Balu Hospital, Madurai,before revival which the life assured had not mentioned in his “Declaration of GoodHealth”.The Insurer had been informed of the life assured’s diabetic condition and theamputation of leg and the proof of it was also available with the Insurer in theirrecords. The physical disability was very much evident and it was not correct topenalize the poor life assured who was very nearly illiterate.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.07.2301Sri.T. ThangasundaramVsLife Insurance Corporation of IndiaAward Dated : 22.01.2007Sri.T.Thangapandi, aged 57 years proposed for insurance on his life at SrivaikuntamBranch of LIC of India on 25.05.2005 and nominated his son, Sri.T.Thangasundaram.Policy bearing number 321718501 was issued under the Endowment Plan for a term of13 years. On 13.06.2005, Sri.T.Thangapandi died at his residence due to stomachpain. Sri.T.Thangasundaram preferred the death claim with the Insurer. The Insurerrepudiated the claim on the grounds that the life assured had withheld materialinformation regarding his health at the time of effecting the insurance.In the hearing on 05.12.2006 the complainant, stated that his father was an agriculturallabourer and had taken a policy one month before his death. The forum put forth thefact that the claim was repudiated on the grounds that the life assured had taken thepolicy by concealing the fact that he was suffering from cancer and the life assured haddied 17 days from the date of commencement of the policy. The complainantintervened and mentioned that the life assured had undergone treatment, but was notaware that the treatment was for cancer. The insurer stated that the life assured hadtaken treatment with Dr. Karmegaraj at Nazareth on 03.01.2005(pre-proposal).

Subsequently he was referred to Tirunelveli Medical College Hospital and the relevantrecords were available in the file. The Claim had risen in just 17 days from the Date ofCommencement of the policy.In the Government Hospital, the life assured was treated in ‘Cancer OP’. It is thereforeevident that the life assured was experiencing severe discomfort and also aware ofavailing treatment for Cancer. In this context it is difficult to accept the complainant’scontention that the life assured was not aware that his disease was cancer. The Insurerhad proved with documentary evidence that the life assured was diagnosed as afflictedby cancer in throat in January 2005 itself. The Forum does not find any reason tointerfere with the Insurer’s decision.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.07.2327Smt. D.ArulmaniVsLife Insurance Corporation of IndiaAward Dated : 22.01.2007On 12.12.2001 Smt.I.Jebaselvi, a beedi roller, proposed for insurance on her own lifeto Cheranmahadevi Branch of LIC of India. The Insurer issued her a policy numbered320970021 for a sum assured of Rs. 25000/- under their Marriage Endowment Plan fora 20 years term. She had nominated her minor daughter and named her mother as the‘Appointee’. Smt.I.Jebaselvi lapsed and then revived the policy on 09.12.2004 bysubmitting a “Personal Statement of Health” dated 07.12.2004. The life assured diedon 28.08.2005. Smt. D. Arulmani, the mother of the life assured preferred the deathclaim with the Insurer. The Insurer rejected her claim on the grounds that the lifeassured had given false answers in the “Personal Statement of Health” submitted byher on 07.12.2004 for reviving the policy.To the hearing on 05.12.2006 the complainant was accompanied by her daughter. Thesister said that the death was due to Asthma and TB. The assured was takingtreatment as outpatient and she was not hospitalized. The Insurer informed that thepolicy was in lapsed condition from March 2004 and the policy was considered forrevival on the strength of DGH. He added that Dr Rajapandian has given a letterstating that the assured was availing treatment for TB for 1 year as outpatient prior torevival.On a careful and dispassionate study of the entire case file, the Forum concluded thatthe life assured was not well at the time of revival but the medical examiner of theinsurer had not noted anything adverse in her on 07.12.004. Also the Insurer shouldhave exercised more care while reviving the policy in view of her occupation. Thereforethe Forum found that the repudiation of the complainant’s claim by the insurer in itsentirety was not justified and that an amount equal to Rs.15000/- be allowed to thecomplainant as an ex-gratia payment.The complaint is partly allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.07.2408Smt. R.JeyamaryVsLife Insurance Corporation of IndiaAward Dated : 22.01.2007

Sri. R.Rajendran submitted a proposal for Life Insurance on his life on 27.01.2003 toLIC of India, Career Agents Branch of Tirunelveli Division. Along with the proposal hesubmitted a medical report of even date from the Insurer’s panel doctor. The Insurerissued him a policy numbered 321328517 under their Endowment Plan for a SA of Onelakh. Sri. R.Rajendran died on 5.12.2005 due to Cardiac Pulmonary Arrest. Hisnominee, Smt. R.Jeyamary preferred the death claim with the Insurer. The Insurerrejected her claim on the grounds that the life assured had suppressed materialinformation, regarding his health at the time of proposing for his insurance. Unhappywith the Insurer’s decision Smt. R. Jeyamary represented to this Forum and agreed tohave the Ombudsman as a mediator.In the hearing the Complainant told the Forum that her husband went to Hospital totake treatment for the sore in the knee. To the question why her husband had availedlong leave the Complainant replied that he availed leave as it was in excess and hewas due to retire. The Insurer presented the case and briefed the reason forrepudiation. Investigation report stated that the life assured was a Diabetic patient formore than 20 years and this was not disclosed in the proposal form.On perusing the relevant documents, it was evident that the Insurer had issued thepolicy after medically examining the life assured. Also the Insurer had repudiated theclaim based on their Claim Investigating Officer’s Report and the Krishna MaternityHome and Pediatric Centre’s case sheet. This case sheet can not be accepted as aconclusive evidence as the patient had been unconscious at the time of admission andthe veracity of the recordings in the case sheet have no corroborative proof. It wouldbe difficult to concur with the Insurer’s decision to repudiate the claim for suppressionof material fact, merely based on the case sheet of the hospital to which the LA wastaken in an unconscious state and from where he never recovered.The Complaint is Allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.04.2407Smt. M.RajeswariVsLife Insurance Corporation of IndiaAward Dated : 22.01.2007Sri.S.Mariappan who was working as an Attender in a Co-Op Bank, submitted aproposal on 19.02.2005 to LIC of India, City Branch-IV of Madurai Division andobtained a Policy numbered 743634688. The policy was for a sum assured ofRs.150000/- with a yearly premium of Rs.9043/- . Sri.S.Mariappan died on 21.04.2005.Smt. M.Rajeswari, the nominee under the policy submitted her claim papers to theInsurer. The Insurer repudiated the claim on the grounds that the life assured hadwithheld correct information regarding his health.In the hearing the complainant told that her husband was in good health and he availedleave only to go on tours and not for taking any treatment. She added that he was notactually suffering from any ulcer nor was he taking any treatment for that. The Insurerbriefed the case and pointed out that the assured had not mentioned in his proposalabout the several spells of leave on medical grounds availed by him and thus deprivedthem of a fair chance of scrutiny. The Forum informed that a claim should not berepudiated only on the basis of medical certificate. The Insurer said that the assuredhad been producing medical certificates from 2001 stating the same reason i.e. Ulcerand also the medical certificates produced by the assured were not from the samedoctor.

All the spells of medical leave have been for the same reason-“Acid Peptic Disease”.However no further details such as diagnostic tests done, and the exact medicinesprescribed etc were available. The insurer was also not able to produce any suchdetails. It is worth observing here that it is not uncommon among employees to availleave on medical grounds even for attending to personal work. However, the factcannot also be ignored that the assured did not mention in the proposal the medicalleave availed by him, about which there is a specific question in the proposal. Thesame disease is mentioned in all the medical certificates even though the doctors whosigned them are different. The life assured was working in a Co-operative Bank whereit may not be possible to avail leave unless there is a genuine need measure. As such,this Forum decided that an amount of Rs.15000/- be made available to the complainanton an ex-gratia basis.The complaint was partly allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.07.2391Smt. Amali Asha ChitraVsLife Insurance Corporation of IndiaAward Dated : 25.01.2007Sri Arockia Selvam submitted a proposal for Life Insurance on his life on 20.9.1999 toNagercoil City Branch of LIC of India. The Insurer issued him a policy for a SumAssured of Rs. 1 lakh bearing number 320678764 under Jeevan Mitra Plan. He revivedthe policy twice- once on 04.09.2001 and once on 14.12.2002. The LA submitted a“Personal Statement of Health” dated 13.12.2002. On 05.08.2004 Sri. G. ArockiaSelvam committed suicide by hanging. Smt. Amali Asha Chitra his wife and nomineepreferred the claim with the insurer. The Insurer rejected her claim on the grounds thatthe life assured had made deliberated misstatements and withheld material informationregarding his health at the time of reviving his policy.In the hearing, the complainant reported that the assured, a constable with BSFdisliked working in the border area and often used to avail leave to be with the family.The Forum enquired about the deceased’s health and behavioral patterns, details oftreatment that he had undergone and grounds of termination of his services from BSF.The insurer informed that the death was due to suicide. The policy was revived twiceinMarch 2001 & September 2002 on the basis of “Declaration of Good Health. Thetreatment taken for mental depression before the date of revival was not disclosed bythe deceased.From the available documents it is evident that the life assured was suffering frommental illness from the year 2000 and was not keeping good mental health. Bysuppressing this important and material fact in his “Personal Statement of Health” thelife assured had misguided the Insurer in reviving the policy on existing rates. Had theInsurer been aware of the LA’s mental condition then their underwriting decision wouldhave been different and they perhaps may not have accepted to revive at all. Also thecause of death is suicide. There is a definite nexus between the illness suppressed andcause of death. Thus the life assured by misrepresenting his real state of healthdeprived the Insurer a fair chance of correctly appraising the risk.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.04.2344

Smt. S.PappaVsLife Insurance Corporation of IndiaAward Dated 25.01.2007Sri. S. Sakkarai raja submitted a proposal for life Insurance on 06.10.2001 to SivakasiBranch of LIC of India. The Insurer issued him a policy bearing number 742831251under their Endowment Plan for a Sum Assured of Rs. 25000/-. He revived the lapsedpolicy on 19.05.2003 by submitting a “Personal Statement of Health” of even date. Sri.S. Sakkarai Raja died on 24.05.2003. Smt. S. Pappa his wife and nominee under thepolicy preferred her claim with the Insurer. The Insurer rejected her claim on theground that the life assured had revived the policy on 19.05.2003 by submitting falseanswers to the relevant questions in the “Personal Statement of Health”.In the hearing, the representative of the Insurer explained the policy details. The policywas an Endowment plan and resulted in Death claim on 24.05.2003.The policy had runfor 1 year 7 months and 16 days. He added that the policy was revived on 19.05.2003and the claim arose within 5 days from the date of revival. Even prior to revival, the lifeassured underwent chemotherapy at Government Rajaji Hospital, Madurai, for HodgkinLymphoma. He further added that the life assured was admitted in Hospital fortreatment on 15.04.2003 and was discharged on the next day i.e. 16.04.2003. Thepolicy was revived on 19.05.2003 and the assured was actually on treatment whilereviving the policy. The claimant came late and the Forum gave her an opportunity tobe heard. The claimant explained that her husband had a painful lump in the neck, aweek before death. He was going to work even at that time. The claimant confirmedthis fact that her husband took treatment at Madurai for 2 days. She said that theywere not aware that such details should have been mentioned in the form when thepolicy was revived.On perusing the above documents it is evident that the life assured was not keepinggood health at the time of reviving the policy. According to the case sheet ofGovernment Rajaji Hospital, Madurai where he had been admitted from 15.04.03 to16.04.03 the life assured had been described as “Patient is a known case of HodgkinLymphoma, now admitted for IV cycle of Chemotherapy”. Thus by suppressing the truestate of his health the life assured had misguided the Insurer in wrongly reviving thepolicy.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.01.2417Smt. VyjayanthimalaVsLife Insurance Corporation of IndiaAward Dated 29.01.2007Sri A.V.Mohan took a Endowment Policy from LIC of India, City Branch XIX, underChennai Division-I, by submitting a proposal for the insurance on 28.03.2004. SriA.V.Mohan died on 20.11.2004. Smt. Vyjayanthimala, his wife and the nominee,preferred her claim with the Insurer. The Insurer rejected the claim on the grounds thatthe life assured had suppressed that he was suffering from Diabetes and UmbilicalHernia.

In the hearing, the complainant stated that her husband had one day slipped andaccidentally fallen down on the other side of the staircase, on the road. He wasbleeding from the leg and head. He was admitted to A.G. Hospitals first and theyadvised him to be admitted to Sri Ramachandra Medical College Hospitals, Chennai.Since he had multiple problems due to the fall he died due to heart attack on20.11.2004. She only knew that he had Umbilical Hernia. The insurer stated that thelife assured died within 7 months and 22 days from the DOC of policy. As per theDischarge Summary of Sri Ramachandra Medical College Hospitals, Chennai the lifeassured died due to Severe Sepsis, DM Type II and Pulmonary Embolism.Dr.M.Chandrasekar of A.G.Hospitals, had stated in Discharge Summary that theassured had a fall from height was treated for fever of 4 days and was diagnosed forUmbilical Hernia, Bilateral Hydrocele, Inguinal Hernia and Renal Azotemia -–known DMnot on any treatment. All these illnesses were not mentioned in the proposal form.Thus it is evident that the Insurer had repudiated the claim based on documentsrelating to a period after the proposal date. The Insurers, in this case, failed toconclusively prove with the aid of clinching documentary evidence that there wasmaterial suppression by the assured to render the contract of insurance voidable.However in view of the fact that there was suppression of Diabetes, Hernia andHydrocele by the assured in his proposal and the ailment ‘Diabetes’ has seriousconnotations when it comes to the underwriting consideration of the insurer, this Forumdecides that an amount equal to Rs.12000/- be given to the complainant in full andfinal settlement of the claim on ex-gratia basis.The complaint is partly allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.05.2406Smt.R.PalaniammalVsLife Insurance Corporation of IndiaAward Dated 29.01.2007Sri. P.Ramakrishnan was a Mazdoor in a Co-Operative Sugar Mill when he submitted aproposal for Life Insurance on his life on 31.03.2004 to LIC of India, Harur Branch ofSalem Division. The Insurer issued him a policy numbered 701718657 under theirEndowment Plan for a SA of Rs.50000/-. Sri. P.Ramakrishnan died on 26.10.2004. Hisnominee, Smt. R.Palaniammal preferred the death claim with the Insurer. The Insurerrejected her claim on the grounds that the life assured had withheld correctinformation, regarding his health at the time of proposing for his insurance.In the hearing the complainant’s brother Sri Senthil M represented her. He stated thatthe LA took policies for the sake of collateral security for the home loan he sought fromDewan Housing Finance Ltd. He was suffering from stomach pain on and off. Normallyanybody would not immediately suspect serious illness and would try to take medicinesso that the pain would subside. Since the pain was persistent they had admitted him toStanley Hospital on 28.04.2004 and later he was again admitted to Stanley Hospital on26.08.2004 for stomach pain. The insurer stated the claim under policy no.701718657was repudiated based on the non-disclosure of details of his stomach pain in theproposal (for 3 months as per the Discharge Summary of the Stanley Hospital).A perusal of the above documents reveal that the life assured had been suffering fromstomach pain, prior to the date of proposal. Regarding the actual diagnosis of thesymptom as Tuberculosis was done only in September 2004- after issue of the policy.

Stomach pain is a symptom and not a disease. It is plausible that the life assured hadnot given much credence to his ‘stomach pain’ on the day he had proposed forinsurance. Had the Insurer obtained details of treatment or medical prescription toestablish severity and frequency of stomach pain then their repudiation would havebeen in order.The Complaint is allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.05.2432Smt.E.MalarvizhiVsLife Insurance Corporation of IndiaAward Dated 29.01.2007Sri. M.Eraniyan (Decd.) obtained an insurance policy with number 701749294 forRs.50000/- from LIC of India, Rasipuram Branch under Salem Division after submittinga proposal on 06.03.2003. The policy was under T-75 (Money Back Plan) with a term of20 years. The life assured died on 18.01.2004. The cause of death was heart attack.When Smt.E.Malarvizhi, the complainant and nominee under the above policysubmitted the claim, the Insurer informed her that nothing was payable under theabove policy as the life assured had withheld correct information regarding his healthat the time of effecting insurance with them.In the hearing the complainant Smt.E.Malarvizhi stated that her husband owned a lorryand he was earning through that business even before their marriage. Her husbandoften used to complain about his headache and fever. All of his complaints wererelated to headache and that too due to cold weather. His death was sudden and sherequested for considering her claim. The Insurer stated the claim arose within 10months from inception and they therefore arranged for an investigation. As per theInvestigating Official who had obtained the medical prescriptions, the life assured wasnot well at the time of proposing for the policy. He had taken treatment from a NeuroSurgeon who had also suggested for MRI Scan during the year 2000 which makes itclear that the life assured was aware of his illness in the year 2000 itself.A perusal of the relevant documents made it clear that the life assured was not ingood health even while proposing for insurance. Had he revealed that he wasfrequently afflicted by breathing problem the Insurer would have called for relevantmedical reports before insuring his life. Thus by suppressing his real state of health thelife assured had misguided the Insurer in assessing the risk.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.006.2420Smt.V.KousalyaVsBirla Sun Life Insurance MumbaiAward Dated 29.01.2007Sri. C.G.Varadharajan, aged 64 years, submitted to Birla Sun Life Insurance, Mumbaian application on 14.10.2005 and was issued a policy of “Flexi Save Plus-To Age” on08.11.2005. He had to pay for 16 years a quarterly premium of Rs. 28170/- to get‘Coverage Face Amount’ of Rs.250000/-. Sri. C.G.Varadharajan died on 04.06.2006 at

KTVR Group Hospital due to “Hepatocellular Failure”. Smt. V.Kousalya, the nomineeunder the policy preferred her claim with the Insurer. The Insurer rejected her claim onthe grounds that the life assured had not revealed that he had suffered from PulmonaryTB with Haemoptysis in the application for insurance dated 17.10.2005.The complainant Smt. V.Kousalya was not present for the hearing. One of the ForumOfficials read out the contents of the complainant’s appeal. The complainant’s maincontention was the way she was treated at the time of investigation, conducted by theInsurer. She also has agreed in her letter that her husband had TB, was undermedication, and as TB is a curable disease, her husband would not have disclosed thesame in the proposal form. The insurer mentioned the details of the policy such as thedate of proposal (14.10.2005), the commencement of the policy (8.11.2005). The lifeassured died on 04.06.2006. On the submission of the claim papers they observed thathis death was due to Hepatocellular failure. Since, it was an early claim they arrangedfor an investigation. As per the discharge record of KTV Medical Foundations Pvt. Ltd.,where it was clearly stated that the policyholder was a case of Cirrhosis of liver, DM,Old Pulmonary Tuberculosis with Haemoptysis. The life assured replied negatively tothe concerned question in the proposal form.It was therefore evident that the life assured had not mentioned that he had sufferedfrom Tuberculosis to the question-3 b) “Have you ever had or sought advice for thefollowing: ‘Asthma, chronic cough, pneumonia shortness of breath, T.B.,or any otherrespiratory or lung disorders?’” in the application for insurance. Had he disclosed thisvital information the Insurer would have called for relevant medical reports and wouldhave accepted at terms different from the present one. By not revealing the exact stateof his health the life assured had deprived the Insurer of correctly assessing the risk.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.08.2498Smt.P.LathaVsLife Insurance Corporation of IndiaAward Dated 29.01.2007Sri.S.Ponmuthu submitted a proposal for insurance on his life on 31.01.1992 atVillupuram Branch of LIC of India. The Insurer issued him a policy for Rs.50000/- underJeevan Mitra Plan. The policy was allowed to lapse due to non-payment of premiumand then revived on 01.03.1995, 28.02.1996, 03.03.1997, 24.02.1998 and lastly on14.12.2004 on the strength of a “Personal Statement of Health”. Sri.S.Ponmuthu diedon 19.06.2005. Smt.P.Latha, his wife and the nominee preferred the death claim withthe Insurer. The Insurer repudiated to settle the full claim on the grounds that the lifeassured had got his policy revived on 14.12.2004 without informing them about his“Nephrotic Syndrome and Hypertension. However the Insurer offered to pay the paid upvalue and bonus that the policy had acquired before it had lapsed.In the hearing the Insurer submitted the various documents on which they had reliedupon to set aside the revival done on 14.12.2004. The complainant, Smt.P.Latha,agreed that her husband had undergone nephrectomy in 2000 but she said that theywere not aware that they should disclose all the treatment particulars in the “PersonalStatement of Health”. The Forum explained to the complainant the concept ofinsurance. It was explained that the Contract of Insurance is a contract of utmost goodfaith and it was essential that the life to be insured -in this case the life assured, who

alone knew his health condition, should inform the Insurer the real state of his health toenable the Insurer to correctly assess the risk.The complainant was convinced about the need to disclose all the relevant changes inhealth conditions to the Insurer at the time of reviving the policy and agreed to acceptthe paid up value and bonus as the claim amount. The Insurer expressed theirwillingness to settle the agreed amount.It was therefore recommended that the Insurer shall obtain consent from thecomplainant and settle the paid up value with bonus as the full and final settlement ofthe claim, as agreed by the complainant.Chennai Ombudsman CentreCase No. : IO (CHN)/21.009.2464Smt.P.NirmalaVsBajaj Allianz Life Insurance Co.Award Dated : 12.02.2007Sri.R.Paramasivam signed on 20.05.2005 a proposal for life insurance and submitted itto Bajaj Allianz Life Insurance office of Chennai. The Insurer issued him a policynumbered 0009379361 under ‘Cash Gain Economy Plan’ with Family Income Benefitand Comprehensive Accident Protection as Riders. Sri.R.Paramasivam died on25.03.2006. Smt. P.Nirmala, the nominee under the policy submitted her claim papersto the Insurer. The Insurer repudiated the claim on the grounds that the life assuredhad not disclosed material facts in his proposal for insurance dated 20.05.2005.In the hearing the complainant told the Forum that her husband was a business manand a contract labour and his death was a sudden one. She agreed that her husbandwas a smoker but used to smoke during night shifts. One of the Officials of the Forumquestioned whether her deceased husband was using hearing aid machine. She repliedthat he was using the hearing aid machine whenever required. She also contended thathe was healthy before his death. The Insurer stated that since it was an early claim i.e.9 months after the proposal, they arranged for an investigation, whereby it wasrevealed that the deceased was a smoker, deaf since childhood and had Chest painearlier. They had also produced to this forum the medical certificate obtained from aGovt. Doctor to prove his deafness. The Insurer also stated that had these details beendisclosed at the time of proposal, they would have asked the Life assured to undergomedical examination like FMR, ECG and would have called for smoking and disabilityquestionnaire.So it was evident that the life assured had not revealed his deformity in the proposalfor insurance dated 20.05.2005 (Here, it is worthwhile to note the general principle thata party of full age and understanding is normally bound by his signature to a documentwhether he reads it, understands it or not). However regarding the Coronary ArteryDisease, the Insurer had neither hospital reports, ECG/other test reports nor medicalprescriptions to conclusively prove that life assured was suffering from Coronary ArteryDisease before proposing for insurance. Further adequate evidence was not producedby the Insurer for proving (a) smoking alone was the cause for Coronary Artery Diseaseand (b) exact onset of the symptoms of heart disease which led to heart attack whichwas the proximate cause of death. To be fair and equitable to both the parties, giventhe circumstances of the case, it was decided that an amount equal to Rs.25000/- beallowed to the complainant as an ex-gratia payment.The complaint is partly allowed.

Chennai Ombudsman CentreCase No. : IO (CHN)/21.08.2431Sri. G.NarayananVsLife Insurance Corporation of IndiaAward Dated : 15.02.2007Smt. N. Saroja submitted a proposal dated 19.07.2003 at Arakkonam Branch, VelloreDivision and obtained a policy bearing number 733135932 for a Sum Assured ofRs.50,000 under Endowment Plan for a term of 20 years. Smt. N. Saroja died due toDiabetic Foot with Sepsis and Cardio respiratory arrest. Sri. G. Narayanan, thenominee of the policy preferred a claim for the benefit under the policy. The Insurerrepudiated his claim on the grounds that Life Assured had failed to disclose that shewas suffering from DM and further that she had consulted a doctor and availedtreatment from him in a hospital.In the hearing the complainant stated that his wife was 45 years old at the time ofdeath. He is working for TWAD Board. He was not aware that his wife had taken apolicy. She used to consult Dr.Booshna Prakash whenever she suffered from anillness. One day she had stepped on a small sharp stone and that caused pain. Only atthat time he came to know that she was suffering from Diabetes. When questionedabout his statement in his letter addressed to the Branch Manager of LIC of India thathis wife was affected by sugar for 2 years and was availing treatment from Dr.BooshnaPrakash of Arokonam, he said that he had approximately stated that she was sufferingfrom diabetes for 2years. The insurer stated that the policy was taken in July 2003 fora Sum Assured of Rs.50,000/- under Endowment Plan for a term of 20 years. Thepolicy had run for 1 year and 10 months. The cause of death was Diabetes Mellituswith ulcer foot. On their investigation they came to know that she was suffering fromDiabetes and was treated by Dr.Booshna Prakash of Arakonam. The complainanthimself had given a letter to the Branch Manager about the treatment undergone by hiswife and that she was suffering from Diabetes for 2 years. The cause of death wasDiabetic Foot with Sepsis.On going through the relevant documents, it is clear that the Life Assured was diabeticfor 5 years before her death (which is before the date of proposal), there is nexusbetween the cause of death and disease that was suppressed and the Insurer hadobtained clinching evidence to prove that the life assured had been suffering fromDiabetes Mellitus before proposal date.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.08.2429Smt. D.RoopavathiVsLife Insurance Corporation of IndiaAward Dated 15.02.2007Sri. K. Devaraj submitted a proposal dated 1 st March 2002 to LIC of India, VaniyambadiBranch under Vellore Division on 04.04.2002 and obtained a policy bearing number731650996 with a date of commencement from 28.03.2002 for a Sum Assured of Rs.1lac under Jeevan Anand Plan. Sri. K. Devaraj died due to heart attack on 7 th February2005. Smt. Roopavathi, his wife preferred a claim for the death benefits, with the

Insurer. The Insurer rejected her claim on the ground that the life assured had withheldthe correct information regarding his health at the time of proposal.In the hearing as the complainant was not present her contentions were read out to theinsurer. In that she alleges that on 13.03.2002, when her husband signed the proposal,the agent, the branch official and Dr. Nurus Syed did not ask her husband any questionon the illness, treatment etc. They were told of only the maturity/death benefits. Shefurther says that they know the agent even earlier and her minor son’s policy was alsocanvassed by him in 1998. If they were asked about the health condition, they wouldhave told the truth. The insurer stated that Sri K.Devaraj, had retired as ADO in StateDevelopment Bank, Dharmapuri. The cause of death stated in the claim form B wasprobable Acute Myocardial Infarction. The Bethesda Hospital Reports, Ambur confirmsthat the assured was availing treatment since 1997 and has been recorded as a knowncase of Diabetes Mellitus Type II, Hypertension, obesity and Upper Respiratory TractInfection from June/1999. The assured was on regular treatment. He had been takingdrugs for Hypertension. The assured was admitted there on 22.06.1999, 03.06.2001,22.06.2001 and 02.02.2005 as in-patient. As per Bethesda Hospital the assured was aregular patient- had Diabetes, Lumbosacral Strain, Osteoarthritis, Respiratory Infection- 10 years’ history. Had he disclosed the ailments they would have called for specialreports.Therefore the Insurer had established beyond doubt that on 13.03.2002, the lifeassured had furnished incorrect information in his proposal. The life assured was aretired bank employee and was very well aware of the gravity of his health conditionand the contention of the complainant that the agent misled them could not beaccepted.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.08.2479Smt. S.DhanalakshmiVsLife Insurance Corporation of IndiaAward Dated 16.02.2007Sri.T.K.Subramani who was working in Southern Railways submitted proposals on30.03.2001 & 31.03.2001 to LIC of India, Arakonam Branch of Vellore Division. TheInsurer issued him two policies-policy number 732126543 for Rs.50000/- & policynumber 732126617 for Rs.25000/- -both under their Endowment Plan.Sri.T.K.Subramani died on 27.10.2002 due to Cirrhosis of Liver. Smt.S.Dhanalakshmi,the nominee under the policies submitted her claim papers to the Insurer. The Insurerrepudiated the claim on the grounds that the life assured had withheld materialinformation regarding his health and habit at the time of effecting the assurance withthem.In the hearing the complainant told the Forum that her husband was working inWorkshop of Southern Railway. Her daughter was also present for the hearing. Therewas delay in claiming the amount as they came to know that her father had takenpolicies only after sometime. She stated that her father was not an educated person tofill up the proposal form. She admitted that her father used to drink. The insurer statedthat the 2 policies taken simultaneously in March 2001 for Rs.50,000 and 25,000 SumAssured under Endowment plan for 13 and 15 years respectively had run for 1 y 7 m.

He was also on leave during 11.04.2000 to 03.05.2000. He died due to Cirrhosis ofLiver with history of taking alcohol.The available documents revealed that the LA had a history of chronic alcohol intake.There was nexus between the information suppressed and the cause of death. Howeverit was also evident that though the life assured was in the habit of consuming alcoholhe was not aware of his liver condition on the day he proposed for insurance. The factcannot be ignored that the assured did not mention in the proposals his habit ofconsuming alcohol, about which there is a specific question in the proposals. Thedisclosure of this information would have helped the insurer to further enquire aboutthe quantity and frequency of alcohol consumption and based on that they would havecalled for special medical reports that may be necessary to have a proper assessmentof risk. Thus keeping the circumstances of the case in mind this Forum concluded thatin the best interests of both the contending parties and to mete ‘equity and naturaljustice’ that an amount of Rs.15000/- under policy number 732126543 and Rs.10000/-under policy number 732126617 be made available to the complainant as full and finalsettlement of the claim under both the policies on an ex-gratia basis.The Complaint is partly allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.08.2411Smt. M.LakshmiVsLife Insurance Corporation of IndiaAward Dated : 19.02.2007On 28.01.2004 Sri. D.Maheswaran an agricultural labourer, proposed for insurance onhis life to Gudiyatham Branch of LIC of India. He proposed for a sum assured of Rs.101000/- under T-75 –A Money Back Plan for 20 years term.Sri. D.Maheswaran died on 08.10.2004 due to fever and vomiting. Smt M.Lakshmi thenominee under the policy preferred the death claim with the Insurer. The Insurerrejected her claim on the grounds that the life assured had withheld correct informationregarding his health at the time of effecting insurance with them. Aggrieved over theInsurer’s decision she represented to the Forum and agreed to have the Ombudsmanas a mediator.In the hearing the complainant stated her husband was asked to take Insurance policyand the agent obtained signature in the forms. They took Insurance for the benefit oftheir children. Her husband was in good health condition. She stated that before deathof her husband, he had problem of vomiting, fever & headache. Regarding the eyeinjury she stated that this was due to the hitting of a stick while working in the field andnothing more than that. As he could not afford the hospital charges he took countrymedicines. When she was asked about the treatment taken by her husband in April,2000 RUHSA Hospital, she accepted that the treatment was taken by her husband asoutpatient. The Insurer stated that this policy was given in January 2004 for a SumAssured of Rs. 1, 01,000/- under Money Back plan for 20 years. The policy had run for8 months and 10 days. The deceased life assured had studied up to 12 th standard asper proposal. The insurer stated that they have repudiated the claim because ofPapilloedema (edema of the optic disk, which may be due to intracranial pressure)mentioned in Claim Form B1 given by RUHSA Hospital, Had the life assured informedthe insurer about the eye injury suffered by him in the proposal, they would have calledfor the Ophthalmic Questionnaire and would have found out whether it was due tohypertension.

Keeping the educational and economic background of the life assured in mind it ispossible that he had no intention of suppressing this information. However the factcannot be ignored that the assured had not mentioned in the proposal the accident ortreatment for his eye ailment for which there is a specific question in the proposal.Therefore it was decided by the Forum that an amount equal to Rs.15000/- be allowedto the complainant as an ex-gratia payment in full and final settlement of the claim.The complaint is partly allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.08.2495Smt.R.RaniVsLife Insurance Corporation of IndiaAward Dated : 19.02.2007Sri. R.Suresh obtained a life insurance policy from Chidambaram Branch of LIC ofIndia after submitting a proposal on 25.10.2004. The Insurer issued him a policynumbered 733625253, under their New Jana Raksha Plan for a sum assured of Rs.30000/-. Sri. R.Suresh died on 20.09.2005 due to Pulmonary Tuberculosis. Smt R.Ranithe nominee under the policy preferred the death claim with the Insurer. The Insurerrejected her claim on the grounds that the life assured had withheld correct informationregarding his health at the time of effecting insurance with them.In the hearing the complainant stated that her son was in good health at the time oftaking insurance. She alleged that the certificate stating that her son had jaundice andtyphoid was baseless and her son never had those diseases. She said that they did notknow the cause of death. He would have died probably due to some poisonous bite.When questioned as what occupation her son was engaged in, she said that he was notgoing for any job but used to go to Tiruppur sometime and work. The insurer statedthat the assured was daily wage earner as per proposal form and was 26 years old. Hedied on 20.09.2005 within 10 months of taking the policy due to Pulmonary TB andAcute Respiratory Distress. Dr.T.Paarivalavan of Primary Health Centre, Kumaratchihad addressed a letter to the Zonal Manager of the Insurer on 30.05.2006, wherein hehad confirmed that the assured was treated by him for typhoid on 02.03.2003, jaundiceon 03.06.2004 and only on 19.03.2005 he was treated for Pulmonary T.B.In this case the life assured was severely anemic and died at the young age of 27 andit appeared that even though Typhoid and Jaundice were cured he was prone to fallsick quite often. By suppressing his diseases for which there was a specific question inthe proposal for insurance, the life assured had denied the Insurer a fair chance ofevaluating the risk correctly. However in view of the fact that the Insurer had solelyrelied on the Claim forms and had not obtained documentary evidence to substantiatetheir decision, the Forum found that the repudiation of the complainant’s claim by theinsurer in its entirety was not fully justified. An amount equal to Rs.10000/- wasallowed to the complainant as an ex-gratia payment in full and final settlement of theclaim.The complaint is partly allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.04.2447Smt.R.PeriakkalVs

Life Insurance Corporation of IndiaAward Dated : 29.01.2007Sri. S.Rasu an agricultural coolie obtained a life insurance policy from LIC of India,Aruppukottai Branch of Madurai Division by submitting a proposal on 31.03.1996. TheInsurer issued him a policy bearing number 741498931 under their Money Back Planwith a Sum Assured of Rs.50000/- and with a premium paying term of 15 years. SriS.Rasu revived the policy three times-on 09.05.2001, on 18.12.2003, and on18.03.2005 by submitting a “Personal Statement of Health” each time. Sri. S.Rasu diedon 19.04.2005. His nominee, Smt. R.Periakkal preferred the death claim with theInsurer. The Insurer rejected her claim on the grounds that the life assured had revivedthe policy on 18.12.2003 by suppressing correct information, regarding his health in the“Personal Statement of Health” of even date. They however offered to pay the paid upvalue with bonus after deducting the outstanding loan and interest.In the hearing the complainant stated that her husband was working as a coolie. Heused to go to the doctor for ordinary fever occasionally. He died on 19.4.2005. Shepreferred the claim with LIC of India. The insurer stated that the assured died on19.4.2005 and the claim arose within 1y 4m of reviving the policy. The cause of deathwas Asthma as per Claim Form. ‘B’ and as per ‘BI’ it was Tuberculosis and the durationof illness was 2 years He further narrated that Dr.Muthusamy of Kariapatti hadconfirmed vide his letter dated 18.9.2005 that the assured was under his treatment forTB for the past 2 years prior to his death. The Insurer contended that the deceased lifeassured was fully aware of the disease and revived the policy and hence the revival ofthe policy was set aside. The claim was admitted for Rs.23,025/- less outstanding loanand interest of Rs.15,850/-.On going through the documents the points are that the Insurer had not obtained thosedocuments like test reports, X-Ray reports or treatment particulars to emphaticallydeclare that the life assured was suffering from Pulmonary Tuberculosis and aware ofthe same on 18.12.2003. Therefore the Forum directed the Insurer to recalculate thepaid up value (and bonus thereon) on the basis that the revival effected on 18.12.2003was valid and rescind the policy money that would have become payable due to therevival effected on 18.03.2005 as the policy holder had died on 19.04.2005 due toBilateral Pulmonary Tuberculosis.The Complaint was partly allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.07.2447Smt.R.PeriakkalVsLife Insurance Corporation of IndiaAward Dated : 27.02.2007On 25.06.2003, Sri. K.Jeyaraj proposed for insurance on his life at Tenkasi Branch ofLIC of India. He proposed for a sum assured of Rs. 50000/- under T-75 –A Money BackPlan for 20 years term. Sri. K.Jeyaraj committed suicide on 17.09.2005. Smt Suromanithe nominee under the policy preferred the death claim. The Insurer rejected her claimas the life assured had withheld correct information regarding his health at the time ofeffecting insurance with them.At the hearing the complainant said that she had a quarrel with her husband over theirdaughter’s marriage. In a fit of rage, he took poison, was hospitalized and died on the

same evening. The complainant’s son reported the death to the police, as advised byhis friends stating that his father took poison unable to bear the disease. They wereafraid of police action against the family if they told the truth. The Insurer said that theassured was suffering from Asthma for 10 years, was taking treatment in a hospital andunable to bear the severity of the disease, the assured had committed suicide. The FIRand the PIR confirm death due to suicide and the cause being the disease. The Insurerdid not conduct any investigation and proceeded with repudiation of claim forsuppression of material fact.The insurer in their wisdom did not conduct any enquiry to find out the veracity of thestatement made in the FIR and PIR and they have also not got any evidence to provethat the deceased life assured did suffer from Asthma for more than 10 years and thathe had suppressed this information while taking the policy in June 2003. Insurance wasgiven to the life assured based upon the medical examination conducted by theinsurance company’s panel doctor who has certified that life assured was enjoyinggood health at the time of taking the policy. The insurer was directed to settle the claimaccording to the conditions of the policy.The complaint is allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.07.2427Sri.I.Gurumurthy & OthrsVsLife Insurance Corporation of IndiaAward Dated : 27.02.2007Smt.I.Muthuvelammal, a milkmaid and aged 47 years submitted a proposal to KovilpattiBranch of LIC of India on 19.03.2004. The Insurer issued her a policy numbered321556533 for Rs. 100000/- Sum Assured, under their Endowment Plan. She hadnamed her husband, Sri.Iranan, as the nominee. Smt.I.Muthuvelammal died on09.01.2005. Sri.Iranan preferred his claim with the Insurer. The Insurer rejected hisclaim as the life assured had withheld material information regarding her health at thetime of effecting insurance with them. Sri.Iranan also died on 31.08.2006.In the hearing the complainants were represented by Sri.Sivakumar. He said that allthe family members got insured. At that time, they took a policy for their mother also.When asked about the illness his mother suffered from, he said that she used to availtreatment whenever she visited her daughter. When asked about the pre-proposaltreatment, he told that he was not aware of the same as he was away at Tirupur. Hepleaded ignorance of her illness as he was away from the family at that time. Thecomplainant requested that the premium paid at least be refunded to him.The Insurer informed that the assured died of heart attack on 9.1.2005 and the preproposaltreatment at R.S.P. Hospital for cancer was not disclosed in the proposalform. The Insurer also mentioned that the assured’s husband had first approached oneagent for insurance on the deceased life assured in March 2004. As the agent did notoblige, the policy was taken through another agent.It is therefore clear that the life assured was in hospital for more than a month and hada surgery performed on her before she proposed for insurance. By answering question11(a), (b), (d), (e) and (i) in her proposal dated 19.03.2004 incorrectly the life assuredhad denied the Insurer a fair chance of evaluating her risk appropriately and misguidedthem in issuing this policy.The complaint is dismissed.

Chennai Ombudsman CentreCase No. : IO (CHN)/21.005.2523Smt Kanchana SampathVsHDFC Standard Life Insurance CompanyAward Dated 27.02.2007Sri M.Sampath Kumar had taken from HDFC Life Insurance Company LTD. a policybearing No. 10101297 for a sum assured of Rs.50000/- under “Unit linked Young StarPlan with Health Option” for a term of 10 years as per his application dated17.10.2004. The life assured died on 17.07.2006. The complainant, who was thenominee under the policy, approached the insurer for the settlement of claim benefits.But the Insurer refused to honour the claim on the plea that the assured suffered fromDiabetes and Hypertension and which fact he did not disclose in his application forinsurance and therefore the policy was declared null and void. The claim for the fullsum assured was repudiated.In the hearing the complainant stated that her husband was a retired IOB LegalOfficer. She said that the agent of the insurer came in person and collected the filled inproposal form. At the time of proposal they had disclosed the facts i.e. the life assuredwas a HT, DM patient for past 10 years and occasionally used to take alcohol etc., tothe agent. But the agent insisted not to reproduce the same in the proposal form. Shealso said that they knew the agent only at the time of inception of the policy. Hercontention was that the agent had misguided them at the time of proposal. Therepresentative of the Insurer stated that the deceased life assured was covered undera HDFC Unit Linked Young Star Plan. She stated that the deceased life assured hadfailed to disclose that he was a known HT, DM patient for 10 years and used tooccasionally take alcohol. Had that been disclosed they would have extended thepolicy after satisfactory medical examination. They had believed in the disclosedstatement made by the deceased life assured and had not insisted on medicalexamination.The DLA being a legally qualified person himself it is difficult to accept that he hadsuppressed material information due to the advice of an agent whom he had just met.Such being the case, the contention of the complainant that they had informed theagent of the Insurer who had only advised them against revealing the real healthcondition is not tenable.The repudiation of the complainant’s claim for the death benefits by the insurer on theground that the insured had withheld material information regarding his health issustainable. However the premium collected by the Insurer included an amount to beinvested in units and it was only fair that this component which did not rely on anymortality chart be paid to the complainant. The Insurer was directed to pay thepermissible value of the allotted units as on 07.02.2007The complaint is partly allowedChennai Ombudsman CentreCase No. : IO (CHN)/21.06.2496Sri A.RamaiyanVsLife Insurance Corporation of IndiaAward Dated 28.02.2007

Sri. R.Kothandapani submitted a proposal dt 29.07.1999 at Thiruvarur Branch ofThanjavur Division and obtained a policy bearing number 752190040 for a SumAssured of Rs.25000/- under Endowment Plan for a term of 15 years. Sri.R.Kothandapani revived the lapsed policy on 09.08.2004 by submitting a “PersonalStatement of Health” of even date. Sri. R.Kothandapani died on 18.11.2004. Sri.A.Ramaiyan, the nominee of the policy preferred a claim for the benefit under thepolicy. The Insurer repudiated his claim on the grounds that Life Assured had failed todisclose in the “Personal Statement of Health” dated 09.08.2004 that he was sufferingfrom Malignant Tumour/ Prostatic Sarcoma and that he had taken treatment at JIPMERHospital.In the hearing the complainant had expressed his inability to attend the hearing. Hehad written in his letter that his son had revived the policy only because the Insurerwould not settle claim if the policy was in a lapsed condition. The complainant’s appealwas read out to the Insurer. The Insurer said that the Investigating Official hadfurnished all details of pre revival hospitalization of the assured. The assured wasdiagnosed for Prostatic Abscess, was admitted in JIPMER Hospital on 10.2.2004,operated upon on 12.2.2004 and was discharged on 15.2.2004. He was readmittedthere with complaints of retention twice with Tender Enlarged Prostate and biopsyrevealed Leiomyosarcoma. Explorative Laparotomy was done on 7.4.2004 followed byChemotherapy. The Insurer said that all these pre-revival treatments were notdisclosed by the assured in the Personal Statement of Health, at the time of revival on9.8.2004. This led to repudiation of claim, the Insurer concluded.In the present case, since the Insurer had established that the deceased life assuredwas suffering from Prostate Cancer and had taken treatment before he revived thepolicy.The complaint was dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.07.2454Sri A.RamaiyanVsLife Insurance Corporation of IndiaAward Dated : 28.02.2007Sri. V.Aathankaraiyan submitted a proposal on 09.04.2002 to LIC of India, VallioorBranch under Tirunelveli Division and obtaineda policy bearing number 321225885, for a Sum Assured of Rs. 84,000/- under theInsurer’s Money Back Plan. The policy was issued with accident benefit. Sri.V.Aathankaraiyan died on 18.10.2005. Sri.V.Vallivel Konar, the nominee under thepolicy preferred a claim for the death benefits, with the Insurer. The Insurer paid thebasic sum assured with bonus but rejected accident benefit on the grounds that noconcrete proof was available to prove accident.In the hearing Smt.V.Krishnaveni who represented the complainant told the Forum thather brother was a milk vendor and also used to graze the cattle. He was bitten by asnake, was given first aid and was hospitalized by a relative at Asaripallam. He wasconscious at that time. The Insurer had settled the claim of Rs.91,381/-. However, theAccident Benefit was not settled. The Insurer said on 11.11.2005, the basic claim ofRs.91,381/- was settled. Though the FIR and PIR confirmed that the death was due tosnake bite, the Post-Mortem Report and the Final Chemical Analysis did not point outany poisonous substance in the viscera and also no internal or external injuries were

found in the body. It was further reported that the death was due to asphyxia and thatthe cause of asphyxia could not be ascertained.Therefore it emerges that we have two contradictory reports. As the Insurer has reliedupon the Post-mortem Report which is a medical and a scientific document this Forumdoes not find it fit to interfere with the Insurer’s decision.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.07.2497Smt S.PetchiammalVsLife Insurance Corporation of IndiaAward Dated : 28.02.2007Sri. P.Subbiah, the deceased life assured was employed as Telephone Supervisor inBSNL. He signed a proposal under medical scheme on 22.02.2003, with LIC of India,Career Agents Branch of Thanjavur Division, to get a life cover for Rs.50000/-. Thepolicy with number 752723512 was under Endowment Plan with a 20 year term. The lifeassured died on 16.04.2004 due to “Right Basal Ganlionic Intracerebral Hematoma.Smt. S.Petchiammal, as the nominee claimed the money from the Insurer. The Insurerinformed her that they were repudiating the claim under the above policy as the lifeassured had given false answers to question numbers 11(a), 11(b), 11(d), and 11(i) inthe proposal.In the hearing the complainant said that the facts given in the proposal form were true.She said that her husband had no serious ailment barring the ordinary cold and cough.He was not well only for a week before death and was treated by Dr.LeninChandrasekar. He complained of chest pain and was taken to MGK Hospital and thento Maruthi Hospital. He died there. She was not aware that her husband hadhypertension. She totally denied that her husband had any illness that necessitatedtreatment. The Insurer said that Dr.Lenin Chandrasekar had issued a certificate thatthe assured had viral fever and had Hypertension for 2 years. He referred to the Proofof Affidavit signed by the doctor. He further added that the assured had failed todisclose details of leave availed by him in the proposal form.On perusing the documents it emerges that the Insurer was not able to get any validproof for the life assured having taken treatment for Hypertension. There is noprescription for medicines from Dr.Lenin Chandrasekaran or any doctor for havingtreated the life assured to substantiate the Insurer’s claim that the life assured was notkeeping good health prior to the date of the proposal. Regarding the medical leaveavailed by the life assured it is not an uncommon practice in Government Offices toapply medical leave to attend to personal work. None of the medical certificates have‘Hypertension’ as cause of leave. The Medical Examiner of the Insurer had notrecorded any treatment (for Hypertension) in his report dated 22.02.2003. Thereforewith the help of available documentary evidences, it would be difficult to conclude thatthe Insurer had satisfactorily discharged his onus of proving fraudulent materialsuppression.The complaint is allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.02.2485Smt N.VijayaVs

Life Insurance Corporation of IndiaAward Dated : 28.02.2007Sri. B.Netharaman had three life insurance policies from LIC of India. All the threepolicies were issued with accident benefit.These policies were serviced by the Insurer’s Ambattur Branch of Chennai Division - IIas the premiums were recovered from Sri. B. Netharaman’s salary by his employer andremitted to LIC of India Ambattur Branch. Sri. B.Netharaman died on 03.04.2005, whilereturning home from work. His wife and nominee under the policies, Smt N.Vijaya,preferred the claim with the Insurer. While admitting the death claim the Insurerrejected to pay accident benefit as the life assured had died while crossing the railtrack.In the hearing the complainant was represented by her brother, Sri. Ramesh. The lifeassured was working in M/s. Devon Machines Pvt. Ltd., Ambattur, Chennai. He usuallyworks in night shifts. The second shift used to be till 11.00 p.m. and he used to returnhome around 12.00 or 12.30 in the midnight. The previous night of the accident hecalled his wife and told that he would return home the next morning. The next morningthey received a call at 09.00 a.m. regarding his death in a railway accident. SriRamesh went to identify the body along with the brother of the life assured. With hisbag and slippers he could identify that he was his brother-in-law. The police told himthat he died while crossing the track. But no one had seen the accident that took place.The insurer stated that the accident benefit claim was repudiated as the life assuredhad committed breach of law. He died while crossing the railway track. He read out thePolice Inquest Report where the police had observed that he had trespassed therailway track and met with the accident. As per the Railway Act crossing the track waspunishable offence. He read out the excerpts of the act and the punishment given forthe same. He also said that as per Section 123 of the Railway Act, death due tocrossing track was not an accident. As per policy conditions also they could not pay thesame since crossing the railway track was breach of law.It is therefore evident that the Insurer has not been able to conclusively prove that thelife assured had committed any breach of law. All the documents that the Insurer hasrelied upon have noted cause of death as “Accident” only.The Complaint was allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.003.2474SRI R. M. AngusamyVsTATA AIG Life Insurance Co. Ltd.Award Dated : 12.03.2007Smt.A.Padmavathi aged about 42 years submitted an application to Tata AIG LifeInsurance Co.LTD. on 22.11.2005 and obtained a Maha Life Policy from the Insurer forRs.2 lakhs after she had paid an annual premium of Rs.14000/-. Smt.A.Padmavathidied on 13.05.2006. Sri. R.M.Angusamy, her husband and nominee under the policy,preferred the claim with the Insurer. The Insurer repudiated the claim on the groundthat the life assured had been under treatment for menstrual disorder and anaemiabefore the date of application and which was not revealed in the application forinsurance dated 22.11.2005.In the hearing the complainant stated that the life assured was a housewife. She wasquite alright except for her menstrual problems for which she used to consult their

family doctor. He admitted that his wife was taking treatment for the last 2 or 3 years.Only before the surgery the Doctor called him and told him that she needs to undergoHysterectomy as she had tumours in the uterus. Based on the trust on the doctor theyadmitted her for surgery. On 13.05.2006 after the surgery she died. The insurer statedthat death occurred on 13.05.2006 within 5 months from the date of risk. Since it wasan early claim they conducted investigations. They found that the deceased lifeassured had menstrual problems prior to taking insurance and the same was notdisclosed in the application form. They got prescriptions dated May 2005 and July2005. The medicines prescribed gave them an indication that she was anaemic relatingto menstrual problems. They had a question viz. question no.9 in the application forinsurance pertaining to female lives and nothing was disclosed for the question by thelife assured. Had she disclosed her ailment they would have called for AttendingPhysician’s report containing facts of the patient, an ultrasound abdomen scan reportand a complete blood profile.Therefore it is evident that the life assured had been consulting a doctor for hermenstrual disorder which is also confirmed by her husband. However it is possible thatthe 43 year old life assured might have thought the undue uterine bleeding asmenopausal and not a serious matter that required to be disclosed. Hysterectomy isquite a common operation nowadays and also the cause of death was due to postoperativecomplications not expected by the life assured. Keeping the circumstances ofthe case in mind and after due deliberation, this Forum concluded that in the bestinterests of both the contending parties an amount of Rs.25,000/- be made available tothe complainant as full and final settlement of the claim under the policy on an exgratiabasis.The complaint was partly allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.05.2557Smt M.EswariVsLife Insurance Corporation of IndiaAward Dated : 15.03.2007Sri. M.Balasubramania Pillai obtained a life insurance policy from Hosur Branch of LICof India after submitting a proposal on 18.02.2003. The Insurer issued him a policynumbered 701729500, under their Endowment Plan for a sum assured of Rs. 1 lakh.Sri. M.Balasubramania Pillai died on 03.01.2006 due to Septicemia. Smt M.Eswari, hiswife and nominee under the policy preferred the death claim with the Insurer. TheInsurer rejected her claim on the grounds that the life assured had withheld correctinformation regarding his health at the time of effecting insurance with them.In the hearing the representative of the complainant stated that his brother was marriedto his sister-in-law in the year 2000. His brother died suddenly on 3.01.06 He statedthat his family members were not aware of his HIV infection. The Forum pointed out tothe representative of the complainant that in the hospital certificate, the deceasedhimself had declared that he was a HIV infected patient from 2002 onwards for the Q.No.8 and it was clearly mentioned that the patient himself gave his history to thedoctor. The insurer stated that the policy commenced from 20.2.03 and thepolicyholder died on 3.1.06. From investigation they came to know that he was a HIVinfected patient and he was aware of the fact before inception. Since, the same wasnot disclosed in the proposal form, they had repudiated the claim due to suppression ofmaterial fact.

In view of the fact that the Insurer had solely relied on the Claim forms and had notobtained documentary evidence to substantiate their decision, the Forum found that therepudiation of the complainant’s claim by the insurer in its entirety was not fullyjustified. To be fair and equitable to both the parties, given the circumstances of thecase, the Forum decided that an amount equal to Rs.20000/- be allowed to thecomplainant as an ex-gratia payment in full and final settlement of the claim.The complaint is partly allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.03.2545Smt M. ParameswariVsLife Insurance Corporation of IndiaAward Dated : 16.03.2007Sri.V.Muthusamy had two insurance policies with LIC of India -763612870 under Plan149 for SA of 1,00,000/- for which he submitted proposal on 14.08.2003 & 762208279under Plan 14 for SA of 50,000/- for which he submitted proposal on 28.02.2004Thelife assured died on 10.09.2005. The Complainant Smt. M.Parameswari claimed thedeath benefits under the above policies. The Insurer repudiated the claim under boththe policies on the ground that the life assured had revived the first policy on19.10.2004 by submitting a ‘Personal Statement of Health’ and obtained the secondpolicy without informing either in the Personal Statement of Health’ dated 19.10.2004or in the proposal dated 28.02.2004 about his renal failure for which he had takentreatment in 2003.In the hearing the complainant stated that her husband was alright till one year oftaking the policy. She said that her husband was taking treatment for blood pressure.When the records of her husband’s pre-proposal illness were shown to her sheadmitted that he was suffering from renal disease. She said that her husband’s sisterwas about to donate her kidney but her husband died before the surgery for kidneytransplantation. She however, pleaded for sympathetic consideration of her claim onhumanitarian grounds since she had two children to be taken care of. The Insurer didnot attend hearing as it was intimated to them that the hearing was cancelled owning tonon-submission of Proforma PIII by the complainant. However the insurer hadsubmitted their ‘Self Contained Note’ where they had enclosed the relevant hospitalrecords to prove that the life assured had suffered from renal disease prior toproposing for insurance.In this case the life assured had suffered from renal disease from 13.08.2003 itself. Bynot disclosing this important information to the Insurer in his proposals and ‘Personalstatement of Health’ submitted at the time of revival the life assured had denied theInsurer a fair chance of evaluating the risk correctly.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.05.2544Smt S.MallikaVsLife Insurance Corporation of IndiaAward Dated : 22.03.2007

Smt.S.Shanthi obtained a life insurance policy by submitting a proposal to LIC of India,Salem South Branch on 30.04.2003. The Insurer issued her a policy numbered701663354 for a sum assured of Rs.1 Lakh under their Jeevan Anand plan and thequarterly premium was Rs.2004/- which the life assured had agreed to pay for 15years. The policy lapsed due to non-receipt of premium due April 2004. Smt.S.Shanthirevived the policy on 10.01.2005 by submitting a Personal Statement of Health dated09.01.2005. Smt.S.Shanthi died on 19.05.2005. Smt.S.Mallika, who was the Appointeefor the minor nominee under the policy, preferred the death claim with the insurer. Theinsurer repudiated her claim on the ground that the life assured had not revealed hercaesarian operation and miscarriage in her Personal Statement of Health dated09.01.2005.In the hearing the representative of the complainant stated that he was an Engineerand engaged in business. He admitted that his first son was born through Caesarianoperation Subsequently in the year 2000 she had a miscarriage during her 2 nd or 3 rdmonth of her second pregnancy. At the time of death also she was pregnant. Theprevious night she complained of stomach pain and they had consulted Dr.Babyusha,their family doctor. The next day around 04.30 a.m. she complained of very severestomach pain and she was taken to the Doctor. She died on the way to the hospital.The importance of the specific questions for female lives in the proposal form waspointed out to him. It was also pointed out that the date of last menstruation in thePersonal Statement of Health has been mentioned as 29.12.2004 as against07.12.2004 recorded in the case sheet maintained by Dr.Babyusha. The insurer the LAwas a housewife. The LA died on 19.05.2005 within 4 months from the date of revival.On investigation they found that the life assured had undergone caesarian operationfor the delivery of her first child. She also had a miscarriage. The details aboutcaesarian operation were not mentioned in the proposal and the details of miscarriagewere not given in the Personal statement of Health. Had she disclosed the details theywould have called for the special reports and assessed the risk properly.It emerges that even though the life assured could not have known about herpregnancy on 09.01.2005 when she signed her personal statement of health, she hadmisled the Insurer by wrongly stating her Date of Last Menstruation as 29.12.2004.Had she noted correctly the Date of Last Menstruation as 07.12.2004 the Insurer wouldhave postponed the revival till the menstruation had commenced. Thus by this wronginformation the life assured had denied the insurer in correctly assessing her risk.14. The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.07.2556Smt. E.ShanmugathaiVsLife Insurance Corporation of IndiaAward Dated 22.03.2007Sri P.Ithaya Kani aged 27 years submitted a proposal on 08.03.2004 to LIC of India,Tenkasi Branch and obtained a life insurance policy numbered 321748671. The policywas for Rs.1.6 Lakhs under the Insurer’s Money Back Plan. Sri P.Ithaya Kani had topay an annual premium of Rs.10091/- for 20 years. On 25.09.2005 Sri P.Ithaya Kanidied at the age of 28 years due to heart attack. Smt.E.Shanmugathai, his wife andnominee under the policy, preferred her claim with the Insurer. The Insurer rejected herclaim on the grounds that Sri P.Ithaya Kani, the life assured, had withheld materialinformation regarding his health at the time of effecting insurance with them.

In the hearing the complainant stated that her father’s house was in Kerala and herhusband i.e. deceased life assured was related to her and she was staying with herhusband before his death at Kadayanallur. She said that her husband died suddenly on21.09.2005 due to heart attack. The wife of the deceased life assured replied that theyknow the reason for repudiation was related to her husband’s HIV illness. She came toknow about his illness only after their marriage. The letter written by the complainant tothe deceased life assured was shown to her, which contained the statement narratingthe HIV infection of the deceased life assured and her awareness on that. She agreedthat it was her letter to her husband when she was in her father’s house. The Insurerstated that the Date of commencement of risk was 15.3.2004. The Insurer produced theletter written by the complainant to her husband, which clearly stated the existence ofHIV in the deceased. The letter proved that she was aware of his illness.On a careful and dispassionate study of the entire case file, this Forum comes to theconclusion that even though there were no medical prescriptions or lab reports relatingto AIDS, the Insurer had obtained a letter written by the complainant to the lifeassured. In the letter dated 01.12.2004 the complainant had written that the lifeassured had been aware of his AIDS illness for the past one year. The complainantalso speaks of visiting Madurai to collect medicines. However the Insurer had notobtained treatment particulars from the concerned hospital in Madurai. Therefore theForum finds that the repudiation of the complainant’s claim by the insurer in its entiretyis not justified. To be fair and equitable to both the parties, given the circumstances ofthe case, the Forum allowed an amount equal to Rs.30,000/- to the complainant as anex-gratia payment.The complaint is partly allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.02.2561Smt. Jeyanthi KothandaramVsLife Insurance Corporation of IndiaAward Dated : 22.03.2007Mr.V.Kothandaraman had seven life insurance policies from LIC of India that hadaccident benefit as a rider along with life cover. Of these seven policies one wasserviced by City branch-IX of Chennai Division-I and the rest by Branches of ChennaiDivision-II. Mr. V.Kothandaraman died on 21.04.2004, while going to work. SmtJeyanthi Kothandaraman, the nominee under the policies preferred the claim with theInsurer. Chennai Division-I paid the basic claim and AB whereas Chennai Division-IIwhile admitting the death claim rejected to pay AB on the grounds that the life assuredhad met with an accident while crossing the track which is a breach of law underSection 147 of the Railways Act 1989. On her representation to the higher office of theInsurer, the Zonal Office allowed Rs. 56500/- on an ex-gratia basis.In the hearing on 23.02.2007 the complainant Smt. Jeyanthi Kothandaraman stated thather husband was not well before the accident. Since, the deceased life assured oughtto join his office; he left for his office on 21 st of April 2004. On his way to his Office, hewas run over by a train and died on 21.4.04. She claimed for the benefit under thepolicy and got the benefits settled under the policy from Chennai Division I. Since, shegot only 50% of the benefits from Chennai Division II, she has approached this Forumfor the full benefits under the policy. Her main contention was that when she got theentire benefits from Branch 9 why not from other branches of the same Insurer. TheInsurer stated that crossing the Railway Track is an offence and punishable under the

act. She stated that as per the station master report, which narrated that, a ‘male agedabout 35 years suddenly trespassed and killed near Egattur railway station’, hence, theInsurer has repudiated the claim under policy condition 10(b) iv and no accidentalbenefit is payable for any breach of law. She also stated that they were not surewhether it was an accident or not. She stated that the word ‘sudden’ given by thestation master clearly established that the deceased life assured was crossing withouttaking precautionary act. During the hearing, it was pointed out to the Insurer that fromthe PIR it was clear that the event was an accident. The Forum stated that underRailway act, trespassing was punishable, but in this case the trespasser could not bepunished since, he was already dead. It was also pointed that trespassing ispunishable under Railway act and Insurance policy was silent in this regard. It isevident that Section 147 of the Railway Act is to help the railways in safeguarding theirproperty and in this instance the insurer has not obtained evidence to prove that thelife assured had committed any breach of law as envisaged under the section.In a recent case the Supreme Court also upheld that the crossing of railway track bynegligence has to be treated as an accident and the relevant extract of the casebetween National Insurance Co. Ltd., Vs Swaran Singh & Ors is reproduced “Accidentincludes negligence. It makes no difference that the accident was caused by thenegligence of the assured (as opposed to his intentional act). Thus there is an accidentwhere the assured crosses a railway line without exercising due care and is knockeddown by an approaching train.”It is also worthwhile to note the extract from the ‘Insurance Treatise of Mac Gillivray’-“Insurance companies have always experienced difficulty in defining the risk which theyare prepared to undertake in an accident policy. In a sense every death or injury,unless intentionally inflicted by the assured himself, is accidental in that its time,manner and cause are unforeseen and unexpected, and insurers have sought to definethe risk much more narrowly.”So it is very clear that the Insurer should have considered all the facts from variousangles before repudiating the accident claim. The argument of the higher office namelythe Zonal Office that some ex-gratia was given purely on humanitarian considerationdid not convince this Forum. Actually the facts of the case do warrant payment ofaccident claim and the Insurer should have paid full amount.The Complaint is allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.01.2563Smt. B.Zarina BegumVsLife Insurance Corporation of IndiaAward Dated : 27.03.2007Sri Buruhanudeen submitted a proposal for life insurance on 09.07.2003 to City BranchVI of LIC of India, Chennai Division I. The Insurer issued him a policy under theirMoney Back Plan. Sri H.Buruhanudeen had to pay Rs.904/- as the quarterly premiumfor 20 years. The policy lapsed since he did not pay the quarterly premium due October2005. Sri. H.Buruhanudeen died on 28.11.2005 due to Cerebro Vascular Accident,renal failure and Uremia. Smt.B.Zarina Begum, his wife and nominee under the policy,submitted the death claim papers to the Insurer. The Insurer rejected her claim on thegrounds that the policy was in a lapsed condition and also that the life assured hadwithheld material information regarding his health at the time of effecting insurancewith them.

In the hearing the complainant stated that her husband was only 39 years old at thetime of death. Her husband had normal health. Suddenly one day he complained ofchest pain and she admitted him to the Government General Hospital, Chennai. TheDoctors told her that he was critical and he might not survive. She came to know thathe had a policy only after his death. She was not aware that her husband had highblood pressure. He never used to take medicines. Whenever he got cough, cold andfever he used go and consult doctors. She had not accompanied him any time. Whenquestioned who would have disclosed the history of her husband’s health to theDoctors she said that she did not know how they have recorded. When questionedabout the admission to Government Royapettah Hospital, Chennai in 2004, she saidthat he was not admitted. Since he was admitted to hospital during his terminal illnessthey could not pay the premium in time and hence the policy had lapsed. He died dueto Heart Attack on 28.11.2005. The first unpaid premium was 10.10.2005. The policywas in a lapsed condition. No paid up value had accrued under the policy. Hencenothing was payable as per policy conditions. The life assured had pre-proposalailments as revealed by the discharge summary of Government General Hospital,Chennai. She said that they could not consider the claim even under their Chairman’sRelaxations for payment of ex-gratia as there was pre-proposal illness.In this instance it is evident that the life assured had withheld the information of hishypertension condition in the proposal. This information was very vital to the insuranceas the life assured had finally succumbed to brain hemorrhage with kidney failure. Hadhe mentioned that he was on drugs for hypertension, the Insurer would have called foradditional requirements and the case would have been underwritten at their higheroffice. By suppressing his correct health condition, the life assured had denied theInsurer a fair chance of correct assessment of risk.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.08.2526Smt. S.NirmalaVsLife Insurance Corporation of IndiaAward Dated 28.03.2007Sri. G. Sivasubramanian obtained a life insurance policy fora SA of Rs.40,000/- under the Jeevan Surabhi (Money Back)Plan from LIC of India, Villupuram Branch on 28.12.1995. Sri. G. Sivasubramanian didnot pay the yearly premium due December 2000. He revived the lapsed policy on13.02.2003 by paying all the premiums that were due and after submitting a ‘PersonalStatement of Health’ of even date and medical report dated 8/2/2003. Sri.G.Sivasubramanian. died on 11.09.2004 due to Multiple Myeloma. Smt. S. Nirmala thenominee under the policy preferred her claim with the Insurer. The Insurer rejected herclaim for the full death benefit on the grounds that the life assured had revived thepolicy on 13.2.2003 without disclosing the treatment taken by him for MultipleMyeloma. The Insurer, offered to settle the paid-up value with bonus accrued under thepolicy.In the hearing, the representative and the son of the complainant stated that his fatherwas working in a Govt. College. Since their claim was repudiated they appealed to theZonal Office and since their appeal did not yield results, they appealed to this Forum.He admitted that his father was not having good health from 1999. But he said that thepolicy was taken in 1995 and he fell ill only in 1999. It was pointed out to him that

evival was almost like a fresh contract and his father was expected to reveal the truecondition of his health at the time of revival also. When questioned he said that he wasaware of the basis of repudiation. The insurer stated that the deceased life assuredwas a Professor in Government Arts College. They had paid 2 survival benefits underpolicy on 28.12.1999 and 28.12.2003 respectively. The policy lapsed in December 2000and subsequently it was revived on 13.02.2003, based on the Declaration of GoodHealth and medical examination after payment of 3 yearly dues along with interestamounting to Rs.15000/-. On investigation they found that the life assured sufferedfrom Multiple Myeloma prior to revival. The Discharge Summary issued by ApolloSpeciality Hospitals, Chennai noted in the history as ‘a known case of MultipleMyeloma’. The Claim Form B also confirmed that the assured was suffering fromMultiple Myeloma since 1999 and the treatment at Apollo Specialities Hospital atChennai. They had submitted the certificates issued by Dr.Thyagarajan for availingvarious spell of sick leave by the life assured prior to the date of revival, which alsostated the same reason. However, the insurer offered to settle the paid-up value withvested bonus after deducting the II survival benefit paid as the revival was held void,which worked out to Rs.5480In this instance it is clearly evident that the life assured who was a learned person hadnot provided the correct information in the ‘Personal Statement of Health’ dated13.02.03 which led the Insurer to wrongly revive the policy for the full Sum Assured. Ifthe life assured had revealed his real health condition of being afflicted by MultipleMyeloma the Insurer may not have revived the policy at all.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.01.2563Smt. R.VeluthaiVsLife Insurance Corporation of IndiaAward Dated : 28.03.2007Sri S.Veluchamy submitted a proposal for life insurance on 10.09.2003 to KovilpattiBranch of LIC of India. The Insurer issued him a policy numbered 321548597 forRs.30,000/- Sum Assured under their New Jana Raksha plan. Sri S.Veluchamy died on06.11.2004. Smt.R.Veluthai, his sister and the nominee under the policy, preferred theclaim with the Insurer. The Insurer repudiated her claim on the grounds that the lifeassured had withheld material information regarding his health at the time of effectingthe assurance with them.The representative of the complainant stated that the life assured was his brother-inlaw.They live in a remote village called Maruthan Kinaru, which is 25 kms. away fromSankarankoil. His brother-in-law was 31 years old at the time of death and was notmarried. When questioned as to why he did not marry he said that he was notinterested in marriage. One day he suddenly complained of stomach ache anddiarrhoea. He became weak and before they could call a Doctor from Sankarankoil hiscondition worsened. He was almost dead by the time the Doctor attended on him. Whenquestioned about the hospitalization at Government Hospital at Sankarankoil from02.09.2003 to 08.09.2003 and the certificate given by Dr.Reghupathy, he said that hewas not aware of the hospitalization since he goes for labour work to Keralasometimes. He denied that his brother-in-law was suffering from T.B. They were alleating together. If it was known that he was T.B. patient they could have kept awayfrom him and given him separate plates etc., since the disease was contagious. The

insurer stated that the life assured was admitted to Government General Hospital,Sankarankoil on 02.09.2003 and he was discharged on 08.09.2003. The doctor hadadvised him to go to Tirunelveli Medical College Hospital for further treatment. He hadsuspected T.B. and referred him to a higher hospital. Within 2 days of his dischargefrom the hospital i.e. on 10 th September 2003 he had proposed for a life insurancepolicy without mentioning the TB or hospitalization. The claims investigating officialhad collected 2 letters from the villages that the life assured was suffering from T.B.for a long time.In this instance the life assured had signed the proposal after getting discharged fromthe hospital which information he had not mentioned in the proposal. Also on08.09.2003, the doctor had discharged him on life assured’s request but againstmedical advice. So it is very evident that the life assured’s health condition was notgood.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.04.2597Sri.L.VellaichamyVsLife Insurance Corporation of IndiaAward Dated : 29.03.2007Smt.V.Muthulakshmi submitted a proposal for life insurance on 10.06.2002 to LIC ofIndia, Dindigul Branch II of Madurai Division. The Insurer issued her a policy numbered743015266 for a sum assured of Rs.50,000/-. Smt.V.Muthulakshmi died of cancer on05.05.2005. Sri L.Vellaichamy the nominee under the policy preferred his claim withthe Insurer. The Insurer rejected his claim on the grounds that the life assured hadwithheld correct information regarding her health at the time of effecting assurancewith them.The complainant Sri. L. Vellaicharmy was not present for the hearing. The contents ofthe letter were that he had approached the Dindugal Branch Office II for death benefitsunder the policy but his claim was denied on the plea that the bills settled to Dr.RaiMemorial Medical Centre, Chennai included a bill dated 22.2.2002 indicating preproposalillness. The complainant had submitted a certificate obtained from Dr.Subramanian, of Dr.Rai Memorial Medical Centre, which has stated that the late Mrs.Muthulakshmi was a tongue cancer patient, and had undergone treatment in theirhospital from 25.10.2002 to April 2003 for external radiation and chemotherapy underDr. Krishnan. During the deceased life assured stay in the hospital, she had undergonelab investigation on 20.2.03, which had been wrongly mentioned in the receipt as22.02.02.The Insurer stated that the deceased Life Assured had taken treatment for tonguecancer at Dr.Rai Memorial Medical Centre, Chennai from 11.10.2002 to 17.10. 2002with external radiation and chemotherapy and paid lab charges on 22.2.2002 at Dr. RaiMemorial Medical Centre, Chennai, which was prior to proposal. Since the Lab Chargesbill showed a date prior to proposal i.e. 22.02.2002 and the claim Form ‘B’ alsosubstantiated that the deceased life assured was suffering from this illness for morethan 4 years, hence, the Insurer had repudiated the claim on the ground that the lifeassured had failed to disclose about his illness at the time of proposal. Insurercontended that they have repudiated the claim based on the date mentioned in the LabCharges bill and in the Claim Form ‘B’ Q. No.5 (f), it was answered as 4 years and

contended that the deceased life assured would been aware of her illness even prior tothe proposal.Dr.Rai Memorial Medical Centre, Chennai is a reputed centre that treats cancer patientand so the Insurer had repudiated the claim as the life assured had got some testsdone there which was proved by the receipt of Dr.Rai Memorial Medical Centre dated22.02.2002. However, as the complainant has now produced proof that it was on20.02.2003 that the lab tests were done and the first consultation at Dr.Rai MemorialMedical Centre was done only in October 2002, the forum finds that whateverevidences for Cancer treatment the Insurer possesses pertain to post-proposal period,which are not relevant for repudiation of the claim.The complaint is allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.04.2590Sri.S.SankarguruVsLife Insurance Corporation of IndiaAward Dated : 29.03.2007Smt.S.Ilavarasi submitted a proposal for life insurance on 27.02.2004 to AruppukottaiBranch of LIC of India. The Insurer had issued her a policy for Rs.50,000/- under theirNew Janaraksha plan. Under this plan age proof is self-declaration made by the lifeassured. Smt.S.Ilavarasi had named her minor son as the nominee. Smt.S.Ilavarasidied on 03.04.2005. Sri S.Sankaraguru, her husband and the Appointee to the minornominee preferred his claim with the Insurer. The Insurer rejected his claim on thegrounds that the life assured had withheld correct information regarding her health atthe time of effecting insurance. His appeal to the Insurer’s higher office was also notfruitful.The complainant Sri. S. Sankaraguru was not present for the hearing. This Forum readout his letter. He has stated that he was a poor farmer and an illiterate. He did notknow the meaning of the policy. His wife died on 03.04.2005 due to cancer. Onsubmission of the claim papers, he came to know that his claim was repudiated. He didnot want to blame anybody for repudiation of his claim. However, he requested thisForum to direct the Insurer to repay at least the premium amount already paid by them,which could be utilized for his son’s treatment of kidney problem. The Insurer statedthat they have repudiated the claim on the grounds that the deceased life assuredfailed to disclose at the time of proposal that she was suffering from Cancer for 3 yearsand had taken treatment in M/s Mohan Nursing Home, where she underwwentChemotherapy, supportive treatment and blood transfusions for Cancer from26.11.2003 to 18.06.2004 The Insurer stated that the deceased life assured hadsuppressed this information in the proposal form.Here the Insurer had proved with medical evidence that the life assured had beensuffering from cancer and also aware of the disease in 2003 itself (prior to proposaldate). Thus by suppressing the true state of her health the life assured had misguidedthe Insurer in wrongly issuing the policy. Had the life assured informed the real state ofher health, the Insurer’s decision would have been different. The life assured’ssuppression had deprived the Insurer a fair chance of evaluating the risk correctly.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.01.2598

Smt.M.PeriakkalVsLife Insurance Corporation of IndiaAward Dated : 29.03.2007Sri P.Muniappan submitted a proposal for life insurance on 09.09.2000 and 07.09.2002to LIC of India, City Branch 16 of Chennai Division I. The Insurer issued him thepolicies numbered 713186124 and 713519726 for a sum assured of Rs.5 Lakhs each,under plan nos.112 and 151 respectively. Sri P.Muniappan died on 11.07.2004 due tocardiac arrest. Smt. M.Periakkal, wife and nominee under the policies preferred herclaim with the Insurer. The Insurer rejected her claim on the grounds that the lifeassured withheld material information pertaining to his health.The complainant stated that her husband was engaged in the building contract workalong with his father. She added that her husband had been to Trichy to attend afunction and after that he went to her father’s house where he died. They were told thathe had died due to heart attack. When questioned whether he had undergone surgeryat Saveetha Dental College Hospital, she admitted that the life assured had undergonesurgery at the hospital in 2002. She admitted that the arrangement of his teeth wouldnot be proper and to correct the same, surgery had been performed. She said thatotherwise he did not have any other illness. When questioned whether her husbandhad undergone any surgery prior to 2002 she said that they were married in 1996 andfor the first time he underwent surgery only in 2002. When questioned about the pasthistory mentioned in the case sheets of Saveetha Dental College Hospital for thesurgery in 2002 where it has been mentioned that he had undergone 7 surgeries earlierin various hospitals, she denied the same. Her father-in-law and father of the deceasedlife assured, who accompanied her to the hearing, admitted that earlier his son hadundergone surgeries twice where even grafting was done.The Insurer stated that they had obtained clear evidence that the life assuredunderwent TMJ surgery in the year 1997 for Ankylosis at Saveetha Dental College andHospital. They had produced a letter from Saveetha Dental College where it has beenmentioned that the life assured had undergone surgical treatment for Ankylosis of TMJtwice in their institution in 1997 and 2002. They had also obtained the case sheetspertaining to his treatment in 2002, where under the past history, details of surgeriesundergone by the patient has been mentioned. She said that Ankylosis meant restrictedopening of mouth. He had not disclosed the details of the surgeries in the proposalforms of the two policies.It is therefore evident that the life assured had undergone a series of operations to setright his facial deformity. The doctor’s noting in 2004 indicate that the repeatedoperations had a bearing on his health. By replying in the negative to the relevantquestions in both the proposals the life assured had denied the Insurer a chance ofcalling for the hospital reports, test reports and other special reports. The Insurerunderwrote the risk without full information. The insurer had proved with medicalevidence the relevance of suppression.The Complaint was dismised.Chennai Ombudsman CentreCase No. : IO (CHN)/21.04.2572Smt.H.Hameela BegumVsLife Insurance Corporation of IndiaAward Dated : 29.03.2007

Sri J. Hussain Mohammed submitted a proposal for life insurance on 15.09.2003 toTirunagar Branch of Madurai Division of LIC of India. The Insurer issued him a JeevanSurabhi policy for Rs.1 Lakh. Sri J.Hussain Mohammed died on 13.09.2005. Smt. H.Hameela Begum, his wife and nominee under the policy, submitted her claim papers tothe Insurer. The Insurer rejected her claim on the grounds that the life assured hadwithheld correct information regarding his health at the time of effecting insurance.In the hearing the complainant stated that her husband had itching in his fingers for thefirst time during May, 2004. Later he had also breathing problem from 2005. They usedto consult Dr.Kamaludeen, their family doctor, for all types of illness of their familymembers like cough, cold, fever etc Dr.Kamaludeen referred her husband toDr.Vivekanandan who was a specialist. The first consultation with Dr.Vivekanandanwas in the clinic of Dr.Kamaludeen and subsequently in Dr.Vivekanandan’s clinic. Theyhad also taken treatment from Dr.Jagannathan. He was not cured even after treatmentin the Government Hospital, Madurai. He died at home. She denied that her husbandwas suffering from either skin disease or lung disease prior to proposing for thisinsurance policy. She was not aware of the contents of the form.The Insurer stated as per claim form B and B1, the life assured was suffering fromInterstitial Lung Disease and Peripheral Vascular Disease for the last 5 years. TheDeceased Life Assured was taking treatment in Government Rajaji Hospital, Madurai13 years back. The same was revealed by the life assured himself as per the Doctor’sstatement. As per Claim Inquiry Report the life assured was suffering from the diseasefor the last 5 years. When questioned about the reporting of the Doctor after thestatement made by the complainant that the doctor was probably displeased with themand hence made such statements, the representatives of the Insurer said that theynever forced the claimant to get the forms from that doctor. On their own will they hadobtained the claims forms B and B1 filled by Dr.KamaludeenA perusal of the documents revealed that the deceased life assured faulted in notrevealing the pre-proposal illness when he took insurance. At the same time theInsurer has rejected the claim purely on the data available in Claim forms B B1 withoutgetting any material or documentary evidences. To reject a claim the Insurer shouldhave definite and clinching evidences. Hence the repudiation of the complainant’sclaim by the Insurer in its entirety was not justified and to be fair and equitable to boththe parties, an amount equal to Rs.30,000/- was allowed to the complainant.The complaint is partly allowed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.03.2616Sri.P.SakthikumarVsLife Insurance Corporation of IndiaAward Dated 29.03.2007Smt.S.Muthulakshmi had obtained a life insurance policy from Pollachi Branch II of LICof India on 15 th March 1999. The policy numbered 762066308 for a sum assured ofRs.50,000/- was issued under the Insurer’s Money Back Plan with accident cover.Smt.S.Muthulakshmi died on 27.09.2005. Sri P.Sakthikumar, her husband and thenominee under the policy, submitted the claim papers to the Insurer. The Insurer paidthe basic sum assured with bonus of Rs.70,700/- on 18.01.2006 but rejected theaccident benefit on the grounds that as per policy condition 10(6)(iv) the accidentbenefit is not payable since travelling in a motorcycle by 3 persons is against the law.

In the hearing, Sri P.Sakthikumar, Husband of Smt.S.Muthulakshmi, the deceased lifeassured and also the complainant under Policy No.762066308 stated that they receiveda message that his sister’s son passed away. From Kinathukadavu, (place of theirresidence) they proceeded to attend the funeral. On their way to his sister’s place, theypicked up Smt. S.Muthulakshmi’s brother-Sri S.Muruganandam. Since there were notenough buses due to construction of Ondipudhur fly over they decided to take SriS.Muruganandam also with them. Sri P.Sakthikumar was driving his bike- TVS Victor.Next to him his brother-in-law was sitting and his wife was sitting after her brother. Itwas dark being night and after nearly 2 Kms. of drive he tried to avoid a Coimbatore toPollachi state transport bus coming on the opposite direction. His bike fell in to a ditchand his wife lost balance and fell down. She suffered from injuries and immediatelythey rushed her to hospital where she died. The decision on the case came to an endrecently and the judgement was given to the RTO and his licence was also released.He was asked to produce a copy of the judgement from the court and the originallicence for verification.The insurer stated that since the accident was caused due to breach of law theyrejected the claim for Double Accident Benefit under policy condition 10(b). He readout the policy condition 10(b). He said that on the basis of FIR and PIR they hadconcluded that it was breach of law since 3 persons had travelled in the bike, whereasonly 2 persons were allowed to travelIn this instance even though the life assured was only a pillion rider she was travellingas one of the three passengers on a motor cycle (which is permitted to carry only 2passengers as per the Motor Vehicle Act) which tantamount to breach of law. Thereforeit is evident that the accident had been due to a breach of law and the Insurer wascorrect, according to the conditions of their policy, in rejecting to pay the accidentbenefit.The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.03.2615Sri.S.MuruganandamVsLife Insurance Corporation of IndiaAward Dated : 29.03.2007Smt.S.Muthulakshmi had obtained a life insurance policy from Pollachi Branch II of LICof India on 15 th March 1999. The policy numbered 761107384 for a sum assured ofRs.25000/- was issued under the Insurer’s Endowment Plan with accident cover.Smt.S.Muthulakshmi died on 27.09.2005. Sri S.Muruganandam, her brother and thenominee under the policy submitted the claim papers to the Insurer. The Insurer paidthe basic sum assured with bonus of Rs.41980/- on 07.01.2006 but rejected theaccident benefit on the grounds that as per policy condition 10(6)(iv) the accidentbenefit is not payable since travelling in a motorcycle by 3 persons is against the law.In the hearing, Sri P.Sakthikumar, Husband of Smt.S.Muthulakshmi, and brother-in-lawof Sri S.Muruganandam,( brother of the deceased life assured) were heard separately.Sri P.Sakthikumar the complainant under Policy No.762066308 stated that theyreceived a message that his sister’s son passed away. From Kinathukadavu, (place oftheir residence) they proceeded to attend the funeral. On their way to his sister’splace, they picked up Smt. S.Muthulakshmi’s brother-Sri S.Muruganandam. Since therewere not enough buses due to construction of Ondipudhur fly over they had decided totake Sri S.Muruganandam also with them. Next to him his brother-in-law was sitting

and his wife was sitting after her brother. It was dark being night and after nearly 2Kms. of drive he had tried to avoid a Coimbatore to Pollachi state transport bus comingin the opposite direction. His bike fell in to a ditch and his wife lost balance and felldown. She suffered from injuries and immediately they rushed her to hospital whereshe died. S.Muruganandam, complainant under policy no. 761107384, agreed to all theabove details. He only added that their cell phone had started ringing and his sisterwas trying to attend the call.The insurer stated that since the accident was caused due to breach of law they hadrejected the claim for Double Accident Benefit under policy condition 10(b). He readout the policy condition 10(b). He said that on the basis of FIR and PIR they hadconcluded that it was breach of law since 3 persons had travelled in the bike, whereasonly 2 persons were allowed to travelIn this instance even though the life assured was only a pillion rider she was travellingas one of the three passengers on a motor cycle (which is permitted to carry only 2passengers as per the Motor Vehicle Act) which tantamount to breach of law. Thereforeit is evident that the accident had been due to a breach of law and the Insurer wascorrect, according to the conditions of their policy, in rejecting to pay the accidentbenefit.The complaint was dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.06.2641Sri.S.ArivoliVsLife Insurance Corporation of IndiaAward Dated : 30.03.2007Smt.K.Mala had obtained a policy from Mannargudi Branch of LIC of India aftersubmitting a proposal on 30.03.2005. The Insurer issued her a policy for one lakhunder their Endowment Plan. Smt.K.Mala had to pay a quarterly premium of Rs.776/-for 34 years. Smt.K.Mala died on 10.11.2005 due to Respiratory failure. Sri S.Arivoli,her husband and nominee under the policy, preferred the death claim with the Insurer.The Insurer repudiated his claim on the ground that the life assured had withheldmaterial information regarding her health at the time of effecting insurance with them.In the hearing the complainant stated that he was working as a Chemistry Professor inGovernment Arts College, Mannargudi. He was married at the age of 28. His wife was22 years old at that time. They waited for one year and since she did not conceive,they started consulting doctors and started treatment for infertility. A Gyneacologist,had advised abdomen scan. From the scan it was found that his wife had small cystsand it was not considered as a problem. The complainant was very clear that his wifewas well and had been consulting doctors for her infertility before proposing forinsurance. After the proposal only the ovarian cancer, removal and treatment hadcommenced. According to the insurer the life assured had been on treatment since1997 which was not disclosed at the time of proposing for life insurance.In this instance the life assured had been on treatment for infertility and also had cystsin her ovary and had symptoms of severe stomach pain for one year which was beforeproposing for insurance. However none of these relevant details were mentioned in theproposal for insurance. This led the Insurer to wrongly issue her the policy undernormal rates.

The complaint is dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.06.2603Sri M.NarayanasamyVsLife Insurance Corporation of IndiaAward Dated : 30.03.2007On 05.11.2003, Sri N.Kannan, aged 23 years, submitted a proposal for life insurance toThiruvarur Branch of LIC of India. The Insurer issued him a policy under their MoneyBack plan for Rs.1 Lakh. Sri N.Kannan had to pay the yearly premium of Rs.6249/- for20 years. Sri N.Kannan died on 02.06.2005 due to septicemia. Sri M.Narayanasamy,his father and nominee under the policy, preferred his claim with the Insurer. TheInsurer repudiated the claim on the ground that the life assured had not disclosed inthe proposal for insurance the treatment he had taken for Chronic Renal Failure inApollo Hospital, Chennai.The complainant’s main argument was that the deceased life assured has writtenvarious exams in the past 10 years. He was working for M/s BSNL, Thiruthuraipoondybranch from 01.04.2002. The deceased life assured developed kidney problem and hadgot treated for the same. After this he was perfectly normal and therefore he had notmentioned it in the proposal.The Insurer rejected the claim as they had received details from M/s Apollo Hospital,Chennai that the deceased life assured had been suffering from Chronic Renal Problemfrom 2000 and had taken treatment in their hospital. The non-disclosure led the Insurerto wrongly issue the policy under normal rates.It was therefore evident that though the life assured had recovered from the renalfailure that occurred in the year 2000, he finally had to undergo renal transplant as hiskidney functions had deteriorated. The relevant information that he had suppressed inthe proposal for insurance dated 05.11.2003 misled the Insurer to wrongly issue thepolicy. As the Insurer had proved with medical evidence that the life assured hadsuppressed material information the Forum found no justification in interfering with theInsurer’s decision.The complaint was dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.01.2671Smt. H. R. KalavathyVsLife Insurance Corporation of IndiaAward Dated : 30.03.2007Sri H.R.Sudalaimani aged 24 years submitted a proposal for life insurance to CityBranch 10 of Chennai Division I of LIC of India on 07.01.2003. The Insurer issued hima policy numbered 713584544 for a sum assured of Rs.1 Lakh. Sri H.R.Sudalaimanidied on 05.12.2005 due to Cardiogenic Shock, secondary to Acute MyocardialInfarction. Smt.H.R.Kalavathy, his mother and nominee under the policy, preferred herclaim with the Insurer. The Insurer rejected her claim on the ground that the lifeassured had withheld material information regarding his health at the time of effectinginsurance with them.

In the hearing the complainant stated he agent simply took signature on the proposalform and they were not aware that details regarding the health condition had to bedisclosed in the proposal form. The agent had taken the proposal and chequesometime in November 2002 itself and the policy was completed only in January 2003.she however had no proof to substantiate this claim. She said that her son had firstcomplained of stomach pain in December 2002. Her son underwent some tests, scansetc., and it was confirmed that he had kidney stones. She said that her son did notavail any treatment before submitting the signed proposal form to the agent. The agentwas responsible for the delayed submission of the proposal form.The Insurer stated that they repudiated the claim on the ground that the assured hadfailed to disclose the details of his pre-proposal treatment for renal calculus. He hadundergone surgery on 15.01.2003. The ultrasound of abdomen taken at Vignesh Scanson 12.12.2002 confirmed that the assured had renal calculi in the upper calyx of rightkidney and middle calyx of left kidney. The assured had undergone tests at Bhabha X-Ray Institute on 16.12.2002 according to which there was evidence of bilateral renalcalculi and right distal urethral calculus with partial obstruction in the right collectingsystem by the distal urethral calculus. . Had he disclosed that he had renal stones theywould have called for special reports along with Kidney questionnaire. Accordingly theywould have underwritten and the decision would be either to postpone or to decline.The Insurer argued that the life assured was a diploma holder and not an uneducatedperson to just sign without reading the contents of the proposal form.It was therefore evident that the life assured was not in good health at the time ofproposing for insurance. The life assured by suppressing the material informationregarding his health had deprived the Insurer a chance of correctly assessing the risk.The complaint was dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.02.2648Smt.V.SaralaVsLife Insurance Corporation of IndiaAward Dated : 30.03.2007Shri V.Suresh Babu had submitted a life insurance proposal dated 30.03.2005. Thepolicy numbered 717640218 with date of commencement as 28.03.2005 from CityBranch 12 of LIC of India, Chennai Division II for a sum assured of Rs.30,000/- wasissued under Table 91- New Janaraksha with accident cover. Shri V.Suresh Babu diedon 13.05.2005 in a road accident. Smt.V.Sarala, his mother and the nominee under thepolicy, submitted the claim papers to the Insurer. The Insurer paid the basic sumassured with bonus of Rs.30,561/- but rejected the accident benefit on the grounds thatthe deceased life assured had been under the influence of alcohol at the time ofaccident.A perusal of records established that the LA had been under the influence of alcohol atthe time of the accident. The complainant’s argument that he was not driving thevehicle is not a valid reason to pay the accident benefit as the benefit is forfeited ifintoxicated. The insurer reproduced relevant portion of the medico-legal manual. Asper the manual if the blood alcohol concentration was between 100 to 300 mg% theperson would have some mental confusion, emotional instability, loss of criticaljudgement, impaired memory, sleepiness, slowed reaction time, loss of muscularcoordination, staggering gait, marked mental confusion, exaggeration of emotions,dizziness, decreased pain response, disorientation and thickened speech. The life

assured must have had all the effects, which resulted in the accident, and hence theyrejected the accident benefit.A perusal of the PMR confirms that the life assured was intoxicated at the time ofaccident. The pertinent policy condition reads as- “The Corporation shall not be liableto pay the additional sum referred in (a) or (b) above if the disability or death of theLife Assured shall be caused by intentional self-injury, attempted suicide, insanity orimmorality or when the life assured is under the influence of intoxicating liquor, drug ornarcotic.” The Forum did not wish to interfere with the policy conditions.The complaint was dismissed.Chennai Ombudsman CentreCase No. : IO (CHN)/21.02.2646Smt. A.JyothiVsLife Insurance Corporation of IndiaAward Dated : 30.03.2007Sri M.Anandan submitted a proposal for life insurance on 09.07.2003 toGummidipoondi Branch, Chennai Division II of LIC of India. The Insurer issued him aNew Janaraksha policy for Rs.50,000/-. Sri M.Anandan died on 20.01.2004.Smt.A.Jyothi, his wife and nominee under the policy, submitted her claim papers to theInsurer. The Insurer repudiated her claim on the grounds that the life assured hadwithheld material information regarding his health at the time of effecting insurance.In the hearing the complainant stated that her husband late Shri. M. Anandan was acoolie and an illiterate. Her husband was hale and healthy before his death. On beingquestioned about her husband’s hospitalization at M/s. Stanley Govt. Hospital in theyear 1982 and the reports of M/s Pavithra hospital during the year 2000, she repliedthat he was admitted in the above said hospitals for headache. She stated that he washaving fever with shivering on the date of his death and he had experienced sweatingwith breathlessness. She contended that he died only due to heart attack and it wassudden and an unexpected one. The Insurer stated that as per the medical recordsavailable it was evident that the deceased life assured had been hospitalized in theyear 1982 for 60 days and he was diagnosed to have Tuberculosis, Jaundice, Anaemiaand giddiness. The deceased life assured was also hospitalized during the year 1991,1992, 1993 and 1999 with complaints of headache. As per the Stanley Govt. HospitalReport, the deceased life assured was diagnosed to have sinusitis and SecondaryDepression during the year 1999. But the deceased life assured had failed to mentionthe same in the proposal form signed during the year 2003. The Insurer also statedthat had that been disclosed they would not have extended the deceased life assuredwith this policy or they would have arranged for detail medical examination. Hence,they have repudiated the claim due to suppression of material facts in the proposalform.Keeping in mind the economic and educational background of the life assured it wouldhave been possible that the details of illness (in the absence of specific questions) hadskipped the life assured’s mind. However as pre-proposal illness was present anamount equal to Rs.10,000/- was allowed.The complaint was partly allowed.Delhi Ombudsman CentreCase No. : LI/DL-III/74/05-06Smt.Shakuntala

VsLife Insurance Corporation of IndiaAward Dated : 25.10.2006Smt. Shankuntala lodged a complaint with this Forum on 25.04.2005 that her husbandlate Shri Jai Bhawan Sharma died on 29.12.2003. His death claim has been repudiatedby LIC of India. She lives in village and is not an educated lady. She has no source ofincome. She has requested this Forum to refund whatever money her husband had paidtowards premium against policy No.330345506 so that she could look after herself withthe money in case the claim is not paid.LIC of India, vide their letter dated 09.05.2005, informed this Forum that the deceasedlife assured took policy on 31.03.1998 for sum of Rs.25000/- at half yearly premium ofRs.973/- with Smt.Shakuntla as the nominee. The life assured, Shri Jai BhagwanSharma, died on 29.12.2003 and intimation was received by them on 13.02.2004. Thenominee under the policy was issued the necessary forms and the same weredeposited by her. The claim was repudiated on 27.07.2004 on grounds of concealmentof material facts regarding his health at the time of revival of the policy. As per theirinvestigation into the claim, they have indisputable evidence to prove that life assuredwas suffering from Pulmonary Tuberculosis and Bronchial Asthma prior to date ofrevival. The deceased did not disclose these facts in his Declaration of GoodHealth(DGH) for the revival of policy. It is evident that these material facts weredeliberately concealed to revive the policy insurance fraudulently. They have conveyedthe repudiation of the claim on 27.07.2004 to Smt. Shakuntala.At the time of hearing, Smt. Shakuntala contested that her husband was not sufferingfrom any disease and he died in the hospital because of chest pain. She pleaded tothis Forum that her claim maybe paid by LIC of India. LIC of India, at the time ofhearing, contested that late Shri Jai Bhagwan Sharma had concealed material factsthat he was suffering from Pulmonary Tuberculosis and Bronchial Asthma at the time ofrevival of the policy and they have rightly repudiated the claim.On enquiry by this Forum whether any medical examination was done at the time oftaking the policy or revival of the policy, the representative of LIC of India onexamination of the file revealed that medical was done on both the occasions – at thetime of taking the policy as well as at the time of revival. On examination of theQuestion No.9 of Medical Examiner’s Confidential Report – Are there any symptoms orsigns suggesting abnormality or disease of the Respiratory system? TheDoctor(Sqn.Ldr.)S.K.Garg mentioned NO in both the reports.In view of the medical examination done at the time of taking the insurance policy aswell as at the time of revival, there being no adverse medical comments, therefore, Iam not in agreement with the observations made by LIC of India, vide their letter dated09.05.2005, addressed to this Forum that late Shri Jai Bhagwan Sharma was sufferingfrom Pulmonary Tuberculosis and Bronchial Asthma prior to the date of revival.I, therefore, pass the Award that Smt.Shakuntala be paid death claim and otherbenefits accrued under policy No.330345506 along with 8% interest from 01.03.2004till the date of payment is made after deducting the amount towards the loan, if any,taken under the policy by the deceased.The Award shall be implemented within 30 days of receipt of the same. The complianceof the Award shall be intimated to my office for information and record.Delhi Ombudsman CentreCase No. : LI/JD-410

Smt.Priyanka MewadaVsLife Insurance Corporation of IndiaAward Dated : 31.10.2006Smt. Priyanka Mewada lodged a complaint with this Forum on 21.02.2005 wherein shestated that her husband late Shri Ghanshyam Mewada had died one and a half yearsback. She is a widow and has been going to the office of LIC of India at Pali andJodhpur. She has also written five letters to the Delhi Office but her claim has not beensettled by LIC of India. What will happen to an ordinary man under thesecircumstances. She further stated that she would be grateful if the claim amount is paidto her within 15 days from the receipt of this letter.LIC of India, vide their letter dated 18.02.2004 addressed to Smt. Priyanka Mewadathat her husband had not paid the premium which was due on 10.10.2000 as a result ofwhich the policy lapsed. The lapsed policy was revived by him on 30.04.2002 on thebasis of Declaration of Good Health submitted by him. He had declared in hisdeclaration thatQUESTIONANSWER2. Since the date of your proposal for theabove mentioned policy:a) Have you ever suffered from any illness/diseaserequiring treatment for a week or more ? NOb) Did you ever undergo ECG,X-ray,Screening,Blood,urine or stool examination ?NO4. Are you at present in sound health ? YESLIC of India has mentioned that they have sufficient proof that late Shri GhanshyamMewada was suffering from Chronic Cirrhosis of Liver which was not declared by him atthe time of revival of the policy, a fact which he had concealed while declaring hishealth in DGH Form. LIC of India has repudiated the claim and has forfeited thepremium paid by late Shri Ghanshyam Mewada.LIC of India, vide their letter dated 23.03.2005, informed this Forum that the claimunder policy NO.100605463 was not payable because as per BHT of Goyal Hospital,Jodhpur dated 28.11.2002, that he was a known case of Cirrhosis of Liver. The policywas revived on 30.04.2002. He was sick before the revival of the policy. On the basisof BHT, an opinion was taken from DMR who in his report stated that late ShriGhanshyam Mewada was a chronic alcoholic who was continuously drinking for the last5 years as a result of which he was a case of Chronic Cirrhosis of Liver. DMR alsostated that he was a patient of Portal Hypertension. As such, the illness was before therevival of the policy.At the time of hearing on 27.02.2006, this Forum has enquired from the representativeof LIC of India whether they had conducted any enquiry from the employer of late ShriGhanshyam Mewada ? Whether he had taken any leave ? Further they should find outwhether he was admitted in any hospital in Pali prior to the revival of the policy .LIC of India, vide their letter dated 20.07.2006 informed the Forum that no record wasbeing maintained for leave taken by late Shri Ghanshyam Mewada by his employer.They further enquired from local Banger Hospital’s surgical ward, who has informedthat Shri Mewada was not admitted from 1998 to 2004.On examination of the various papers submitted by LIC of India, it is observed that lateShri Ghanshyam Mewada was first admitted in Goyal Hospital and Research Centre,

Jodhpur on 11.11.2002 and was discharged on 06.12.2002. In the Discharge summaryof the hospital, it is mentioned that the patient Shri Ghanshyam Mewada was a knowncase of Cirrhosis of Liver and a chronic alcoholic. It is evident that late ShriGhanshyam Mewada who revived the policy on 30.04.2002 was a patient of Cirrhosis ofLiver which was not disclosed in the DGH Form filled in by Shri Ghanshyam Mewada,which amounts to non-disclosure of material fact. He had a previous history ofCirrhosis of Liver and was an acute alcoholic. This fact has been confirmed at the timeof admission at Banger Hospital on 10.11.2003 where it is mentioned that late ShriGhanshyam Mewada was a known case of Cirrhosis of Liver. It is further confirmed byDr. Arvind on 11.11.2003 that as per the history and clinical findings, it is a knowncase of chronic alcoholis, alcoholic liver disease haemetiasis-blood loss-ARF.Therefore, it is confirmed that late Shri Ghanshyam Mewada has wrongly declaredabout his health that he has been enjoying good health at the time of revival of thepolicy. It is in contrary to the medical history at the time of admission in GoyalHospital, Jodhpur where it is mentioned that he was a patient of Cirrhosis of Liver andchronic alcoholic.I, therefore, uphold the decision of Life Insurance Corporation of India repudiating theclaim of Smt. Priyanka Mewada.There is no further relief to be granted to the complainant.Complaint is disposed of finally.Delhi Ombudsman CentreCase No. : LI/BK-335Smt.Koshalya DeviVsLife Insurance Corporation of IndiaAward Dated : 30.11.06Smt. Koshalya Devi lodged a complaint with this Forum on 14.12.2004 that she had notreceived the payment during the last 4 years after the death of her husband. LIC ofIndia had repudiated the claim on 30.03.2002 on the grounds that her husband used toconsume Alcohol which is not true. If her husband was sick why did LIC of India issuea policy to him. When LIC of India has taken the responsibility to pay for the death ofher husband they cannot be absolved of their liability.The representative of LIC of India during the hearing said that LIC of India hasrepudiated the claim vide their letter dated 30.03.2002, on the basis of suppression ofmaterial fact in the proposal form. He informed the Forum that the life assured wassuffering from Alcoholic lever disease and he was addicted to alcoholism.The complainant informed the Forum that the deceased has not taken any leave fromthe office and was not alcoholic.On examination of the papers submitted and after hearing both the parties, it isobserved that LIC of India had obtained a certificate from the employers of late ShriSriram Meena wherein the leave record for the year 1997 to 2000 was presented andon examination of the same, it was observed that late Shri Sriram Meena had onlytaken 5 days sick leave during the last 4 years.He was admitted in the Railway Hospital on 30.11.2001 where he was advised to bereferred to Civil Hospital, Hanumangarh and as per the BST NO.116861 dated30.01.2001 of Government hospital, Hanumangarh, it is mentioned “Known alcoholicsince 30 years” on the basis of which LIC of India has repudiated the claim for nondisclosureof material fact in the proposal form. It is evident from the leave records that

Shri Sriram Meena had not taken any sick leave except for 5 days and other leaveswere taken for domestic work. As such it can be presumed that he has been consumingAlcohol for the last 30 years and I do not consider it material for LIC of India torepudiate the claim since he has been performing his duties.I, therefore, pass the Award that Smt. Koshalya Devi be paid the sum assured alongwith other accrued benefits under the policy together with 8% interest from 01.02.2002till the time payment is made.The Award shall be implemented within 30 days of receipt of the same. The complianceof the Award shall be intimated to my office for information and record.Delhi Ombudsman CentreCase No. : LI/BK-419Smt.BismillaVsLife Insurance Corporation of IndiaAward Dated : 30.11.06Smt. Bismilla had lodged a complaint with this Forum 08.03.2005 that her son late ShriSamsuddin had taken a life insurance policy on 28.06.2001 for Rs.25000/- and the lifeassured has expired on 30.04.2004. She had completed all the formalities and wasadvised by LIC of India on 15.02.2005 that her claim has been repudiated. The reasonsfor repudiation were not valid. She has requested the Forum to settle the claim.LIC of India, vide their letter dated 17.01.2006 informed the Forum that during theirinvestigation, it was revealed that the life assured was handicapped at the time ofproposal. He was not in a position to move. The deceased life assured had applied forHandicap Pension from BDO, Panchayat Samittee, Nohar in the year 1999 which hasbeen confirmed by a letter from the Panchayat Samittee dated 09.11.2004. Thedeceased life assured had suppressed material information regarding his health andLIC of India had repudiated the claim on the grounds of concealment of material fact.This Forum has written a letter to LIC of India to get a confirmation from the StateGovernment whether the deceased life assured, Shri Samsuddin, was getting anypension from the State Government and any disability certificate was enclosed with theapplication with the State Government.At the time of hearing, the representative of Smt. Bismilla disclosed that late ShriSamsuddin was not getting any pension from the State Government. However, familypension was being given by the employer of his father.LIC of India, at the time of hearing, contested that the life assured had suppressedmaterial information regarding his health since he was a handicapped for the last 2years before the date of proposal and was not in a position to move. He had notdisclosed this material information in the proposal form submitted with the LIC of India.He had also applied for pension with the State Government. On enquiry by this Forumthat since LIC had received the Agent’s Confidential Report whether it was not the dutyof the agent to disclose that late Shri Samsuddin was handicapped which he has notdisclosed under Column III of his report . What action LIC of India had taken againstthe agent ? The representative of LIC of India informed the Forum that they had nottaken any action against the agent. Further, on enquiry from the representative of LICof India whether any disability certificate was obtained, the representative had noknowledge of the same.On examination of the papers submitted, it was observed that the life assured, ShriSamsuddin, was a handicap person as per the enquiry conducted by the LIC of India.

He had concealed the material fact that he was handicap. However, the agent in hisConfidential Report has not mentioned any disability of the life assured which showsthat the concealment of material fact by the life assured was not material since in theconfidential report, the agent has not given the true and fair picture of the life assuredto the Corporation.I am not in agreement with the decision of Life Insurance Corporation of India inrepudiating the claim of Smt. Bismilla. Since it is the duty of the agent to give true andfair picture of the life assured so as the risk could be under written properly. Further,LIC of India has not taken any action against the agent. LIC of India has also not triedto verify whether he got any pension from the State Government given to handicappedpersons nor they have been able to produce any disability certificate of Shri Samsuddinconfirming the degree of disability.I, therefore, pass the Award that Smt. Bismilla be paid the sum assured along with theother benefits accrued under the policy by LIC of India.The Award shall be implemented within 30 days of receipt of the same. The complianceof the Award shall be intimated to my office for information and record.Delhi Ombudsman CentreCase No. : LI/BK-10/05-06Shri Rupa RamVsLife Insurance Corporation of IndiaAward Dated : 30.11.06The complaint was heard on 15.11.2006. The complainant, Shri Rupa Ram, wasabsent. He was also absent on the earlier date on 21.08.2006. LIC of India wasrepresented by Shri K.C.Sharma, Manager(Claims).Shri Rupa Ram had lodged a complaint with this Forum on 21.03.2005 that his mother,Smt. Mohni Devi, had taken LIC Policy No.501317047 for Rs.50,000/- from theirSujangarh Branch. After her death, he filed a claim with the LIC of India. LIC of Indiaon 29.10.2004 repudiated the claim on the grounds that Smt. Mohni Devi was sufferingfrom Dysphagia before taking the policy. The truth is that his mother was not sufferingfrom any disease. She was medically examined before the proposal was accepted byLIC of India. LIC of India has accepted her proposal only after her medical examinationthen how can the Corporation come up with the excuse that she was not keeping goodhealth. Their contention that she was not keeping good health is not true and baseless.He has requested the Forum to pay the claim.LIC of India, vide their letter dated 28.11.2005, informed the Forum that they hadrepudiated the claim on 29.10.2004 due to concealment of material fact. The policyholder was suffering from Dysphagia before taking proposal.At the time of hearing, the Forum raised a question that since medical was conductedin the case of Smt. Mohni Devi, how the doctor could not detect the disease ofDysphagia since she had difficulty in swallowing which should have come out ondiscussions with the life assured about her medial history. Even the agent has notmentioned about the disease in his report. Both the doctor and the agent have beennegligent at the time of proposal being made to LIC of India.On examination of the papers submitted by LIC of India, it is observed that as per thedischarge certificate of Acharya Tulsi Cancer Hospital where Smt. Mohni Devi wasadmitted, it is mentioned that she was suffering from Dysphagia for the last two years.She had expired on 19.02.2004 and she had taken the insurance policy on 14.08.2003.

She was very much aware of the disease which she has not disclosed resulting inconcealment of material fact. Therefore, LIC of India has rightly repudiated the claim.I uphold the decision taken by Life Insurance Corporation of India repudiating the claimof Shri Rupa Ram under policy No.501317047.There is no further relief to be granted to the complainant.Complaint is disposed of finally.Delhi Ombudsman CentreCase No. : LI/UP-140/05-06Smt.KanaklataVsLife Insurance Corporation of IndiaAward Dated : 30.11.06The complaint was heard on 15.11.2006. The complainant, Smt. Kanaklata, waspresent. LIC of India was represented by Shri Prahlad Rai Tailer, AdministrativeOfficer.Smt. Kanaklata lodged a complaint with this Forum on 07.06.2005 that her latehusband Shri Prakash Chandra Sharma had taken two policies No.180378317 and181987198 from LIC of India, Dungerpur Branch. He expired on 06.04.1994. She hadcompleted all the formalities with regard to the payment of the claim against thepolicies. However, she shifted to Mumbai to look after the shop. She moved her familyalong with children to Mumbai after completing the formalities for payment of claim withLIC of India and on the verbal assurance of her relatives and the insurance agent tolook after her insurance claim but till date she has not received any amount against theabove mentioned two policies. She requested the Forum to get her claims approvedfrom LIC of India.LIC of India, vide their letter dated 16.08.2005 informed the Forum that the details ofthe policies are as under:-Policy No. 180378317 1819871981. Date of commencement : 28.03.1991 28.01.19932. Date of FPR : 31.03.1991 31.03.19933. Date of Revival : 23.04.1993 —-4. Sum Assured : 50000 500005. Mode : Hly Hly6. Instalment of premium : Rs.1410.80 Rs.1470.007. FUP : 28.03.1994 28.07.19948. Date of Death : 06.04.1994 06.04.19949. Cause of Death : Lungs Cancer10. Duration of Policy fromFPR/Revival : 11 months I year 5 days13 days11. Status of policy : In force death reportedLIC of India issued a series of letter resting with letters of death claim/18B dated29.07.1997 for submission of claim forms 3783,3784,3816 to the claimant Smt.Kanaklata Sharma. She did not comply the requirements hence the claim had not beensettled. The claimant has now submitted claim form 3783(R), 3785 dated 06.07.2005.

They further needed claim forms No.3784,3816 death certificate and policy bonds forconsidering the death claim. They have asked the claimant to submit the documentswithout further loss of time.The complainant, Smt. Kanaklata informed the Forum on 21.08.2006 that she had withgreat difficulty managed to get the duplicate certificates and necessary documentscompleted from the treating doctor.LIC of India informed the Forum vide their letter dated 06.01.2006 that they hadrepudiated the claim since late Shri Prakash Chandra Sharma was suffering from feverand pleural effusion of lungs and taken treatment for Adeno Carcinoma long withpleural effusion before the date of FPR 31.03.1993 under policy No.181987198 andfrom the date of revival 24.03.1993 under policy No.180378317. Smt. Kanaklata wasinformed accordingly.Since LIC of India could not produce the letters sent to Smt. Kanaklata, the case wasadjourned for next date for LIC of India to produce the letters sent to her.On 15.11.2006, the complaint was again heard and LIC of India produced the lettersdated 21.08.1998 by Registered post under Policy No.180987198 written to Smt.Kanaklata informing her that the claim stands repudiated since the details furnished inthe proposal form were incorrect as late Shri Prakash Chandra Sharma was alreadysuffering from fever and pleural effusion of lungs which he had concealed in theproposal form. Acccordingly, the claim stands repudiated for non-disclosure of materialfact. Further LIC of India had also informed Smt. Kankalata vide their letter dated21.08.1998, by Registered Post, repudiating the claim under policy No.181378317 thatthe declaration made in the proposal form by late Shri Prakash Chandra Sharma wasincorrect. Prior to revival of policy, Shri Sharma was suffering from fever and pleuraleffusion of lungs. He had concealed the material fact by submitting certificate of goodhealth. Accordingly, the claim was repudiated.Smt. Kanaklata Sharma deposed before the Forum that she has not received the letterssent by LIC of India and she had been contacting their Udaipur Office andsubsequently their Dungerpur and Sagwara Branch in this regard. She also submitted aletter to the Forum wherein she has mentioned that LIC of India officers were directedto settle the claims. This statement of Smt. Kanaklata Sharma is incorrect. The Forumonly advised LIC of India to produce the letters written to Smt. Kanaklata Sharma in theyear 1998 repudiating the claim and her letter is irrelevant and baseless. She pleadedthe Forum that she should be paid her claim by LIC of India.LIC of India informed the Forum that they had sent letters under both the policies byregistered post to Smt. Kanaklata Sharma on 21.08.1998 on the basis of medicalattendant certificate of Dr.J.C.Kothari wherein he has mentioned that late Shri PrakashChandra Sharma was suffering with the disease of fever and pleural effusion of lungsand taken treatment for Adeno Carcinoma in the hospital on 01.04.1993. PolicyNo.180378317 was revived on 23.04.1993 and the first premium receipt was31.03.1993. Late Shri Prakash Chandra Sharma was very well aware of the disease asa result of which he died on 06.04.1994. He had concealed the material fact in theproposal form submitted to the Corporation. LIC of India has rightly repudiated theclaim.On going through the papers and after hearing both the parties, it is observed that ShriPrakash Chandra Sharma died on 06.04.1994 and LIC of India had repudiated theclaim on 21.08.1998. As per the RPG Rules,1998, only complaints which are less thanone year old should be entertained and LIC of India having repudiated the claim in theyear 1998, the complaint was time barred. However, this Forum has examined the

documents submitted and also the medical attendant’s certificate issued byDr.J.C.Kothari of Bombay Hospital on 19.02.1998 which are as follow:-4(c) How long had he been suffering One year from date offrom this before his death ? : Diagnosis, that is,date of death 06.04.1994(d) What were the symptoms : Aden carcinoma lungof the illness?with Pleural effusion and fever(e) When were they first observed : When he was admittedby the deceased ?in Bombay: Hospital on 01.04.1993The insured had revived the policy No.180378317 on 23.04.1993 after his admission inthe hospital and in the case of Policy No.181987198, the first premium was paid on31.03.1993. Late Shri Prakash Chandra Sharma was very much aware of the diseasehe was suffering from and has concealed the material fact. Therefore, LIC of India hasrightly repudiated the claimI uphold the decision taken by Life Insurance Corporation of India repudiating the claimof Smt. Kanaklata Sharma under the above policies.There is no further relief to be granted to the complainant.Complaint is disposed of finally.Delhi Ombudsman CentreCase No. : LI-JD/263/05-06Smt. Maya DeviVsLife Insurance Corporation of IndiaAward Dated : 23.11.06My office has received a complaint on 16.09.2005 from Smt. Maya Devi, against theLife Insurance Corporation of India, Divisional Office-Jodhpur, regarding non-paymentof Death Claim under policy No. 103036488The representative of Life Insurance Corporation of India, Jodhpur Division, during thehearing on 14.11.2006 informed vide their letter dated 18.10.2005 that the policy hasnot even acquired paid up value. The policy is in lapsed condition. Half yearly premiumdue on 14.3.2005 was not paid to Life Insurance Corporation of India. Life assuredexpired on 24.07.2005. No risk was covered under the terms and conditions of policycontract. Therefore, Death claim was not payable. I uphold the decision of LifeInsurance Corporation of India,There is no further relief to be granted to the complainant.The complaint is disposed of.Delhi Ombudsman CentreCase No. : LI-JP/275/05-06Smt. Kakayi DeviVsLife Insurance Corporation of IndiaAward Dated : 23.11.06My office has received a complaint on 02.03.2006 from Smt. Kakayi Devi that the LifeInsurance Corporation of India, Divisional Office-Jaipur, has not paid the Death Claim

on life of her husband Late Shri. Ram Charan Jatav under policy No.191482116. Smt.Kakayi Devi is the nominee under the policy.The representative of Life Insurance Corporation of India, Divisional Office-Jaipur,during the hearing on 14.11.2006, informed vide letter dated 05.07.2006 that the policywas in a lapsed condition. Yearly Renewal Premium due on 10.4.1998 was not paid toLife Insurance Corporation of India. Life Assured expired on 16.09.2003. Risk underthe policy was not covered as per terms and condition of policy contract. Policy has notacquired paid up value. Policy commenced with effect from 10.04.1997 and only firstyearly premium due on 10.04.1997 was paid . Death Claim is not payable under thePolicy and I uphold the decision of Life Insurance Corporation of India.There is no further relief to be granted to the complainant.Therefore, the complaint is disposed ofDelhi Ombudsman CentreCase No. : LI-JD/214/05-06Sh. Manohar LalVsLife Insurance Corporation of IndiaAward Dated : 27.11.06My office has received a complaint on 02.08.2005 from the complainant Sh. ManoharLal that the Life Insurance Corporation of India, Divisional Office-Jodhpur,, hasrepudiated the Death Claim on life of his mother Late Smt. Geeta Devi under policyNo.10056498, on basis of suppression of material facts.Hearing of the complaint was fixed for 14.11.2006, Shri Manohar Lal, complainantattended the hearing Shri. R.N. Meena, Manager (claims) Life Insurance Corporation ofIndia Division Office- Jodhpur attended the hearing on behalf of Life InsuranceCorporation of India.Policy commenced with effect from 26.11.1998 under Table Term 14-18 for SumAssured of Rs. 25000/-. The policy was revived on 28.12.1999 on the basis ofdeclaration of Good Health and premium due Half yearly May-99 and November-99were paid at the time of revival of Policy. Life Assured expired on 29.06.2000.Life Insurance Corporation of India vide their letter No claim /death/ 100564980 dated30.06.2001 has repudiated Death claim on ground that material facts regarding healthof Life Assured were not disclosed on form of declaration of Good Health at the time ofrevival of Policy.As per the prescription of Dr. Pratap Sancheti of Jodhpur, Life Assured Smt. GeetaDevi was suffering from the Rheumatic heart disease, Atrial Fibrallator, Mitral Stenosissince 26.09.1999.I uphold the decision of Life Insurance Corporation of India that the death claim is notpayable.Delhi Ombudsman CentreCase No. : LI-JD/21/05-06Smt. Uchhab KanwarVsLife Insurance Corporation of IndiaAward Dated : 27.11.06

Smt. Uchhab Kanwar made a complaint to this Forum on 22.03.2005 that Life InsuranceCorporation of India Jodhpur Division, has not paid Death Claim under Policy No.102911549. Policy was on the Life of Shri. Laxman Singh who was the son of thecomplainant.Hearing of the complaint was held on 14.11.2006 Smt. Uchhab Kanwar attended thehearing. Shri R.N. Meena Manager (claims) Life Insurance Corporation of India ,Jodhpur, attended the hearing as official representative. Life Assured Shri. LaxmanSingh , aged 20years expired on 27.01.2004. Policy commenced with effect from26.12.2003. Sum assured under the Policy is Rs. 30000/-.Life Assured expired due to congestive cardiac Failure in M.G. Hospital, Jodhpur on27.01.2004, within one month from taking the Insurance Policy. Life InsuranceCorporation of India , vide their letter dated 15.02.2005 has repudiated the claim onthe ground that the material information regarding health was not mentioned correctlyin the proposal form at the time of taking the Insurance Policy.As per the record of M. G. Hospital, Jodhpur, BHT No. 1233/E dated 26.01.2004,duration of previous illness has been mentioned as 10 years since early childhood.I uphold the decision of Life Insurance Corporation of India vide their letterdated 15.20.2005, repudiating the Death Claim.Complaint is disposed of.Delhi Ombudsman CentreCase No. : LI-JP/72/05-06Smt. Santara DeviVsLife Insurance Corporation of IndiaAward Dated : 27.11.06Smt. Santara Devi made a complaint to this Forum on 25.04.2005 that Life InsuranceCorporation of India Jaipur,, Division, has not paid Death Claim under Policy No.191785035 on the Life of her husband Shri. Dev Karan Mali .Hearing of the complaint was held on 14.11.2006 Shri Ram Avtar Mali relative of thecomplainant attended the hearing. Shri N.L. Moondra, Manager (claims) Life InsuranceCorporation of India , Jaipur, attended the hearing as official representative.Life Assured Late Shri. Dev Karan Mali, purchased Insurance Policy for Sum Assuredof Rs. 25000/-. The policy commenced with effect from 28.03.2000. Insurance Policywas revived on 08.09.2003. Life Assured expired due to brain stroke on 09.09.2003 atSaudi Arabia. Life Assured was not present in India on 08.09.2003 when the policy wasrevived and his signatures on the Declaration of Good Health were found forged by theHand Writing Expert. Life Insurance Corporation of India vide their letter dated02.12.2004 repudiated Death Claim on the ground that Life Assured was not present inIndia and was abroad as on 08.08.2003 which is date of Declaration of Good Healthand date of revival. Policy was revived with fraudulent intention by making forgedsignature of the deceased Life Assured on Declaration of Good Health.I uphold the decision of Life Insurance Corporation of India vide their letter Ref No.claim/D/Rep/48/191785035 dated 02.12.2004 Ref NO: claim/D/rep./48/191785035,repudiating the Death Claim.Complaint is disposed of.

Delhi Ombudsman CentreCase No. : LI-UP/211/05-06Smt. Mangla SreemaliVsLife Insurance Corporation of IndiaAward Dated : 23.11.06Smt. Mangla Sreemali has lodged a complaint on 01.08.2005 with this Forum that LifeInsurance Corporation of India, Divisional Office-Udaipur has not settled Death Claimunder her husband Late Sh. Manoj Shreemali under Policy No. 182591210.The Life Insurance Corporation of India Udaipur Office, has informed during thehearing on 15.11.2006 that they have already made the payment of Rs. 298456 videtheir cheque No. 352337 dated 03.03.2006. After receipt of payment the complainanthas lodged the complaint to Hon’ble District Consumer Forum Udaipur vide case No.32/06 on the same subject matter, hence complaint does not lie with the InsuranceOmbudsman as per RPG rules 1998, under 13 (3) (C).There is no further relief to be granted to the complainant.The complaint is disposed of finally.Delhi Ombudsman CentreCase No. : LI-DL-I/61/06Smt. R. SellammalVs.Life Insurance Corporation of IndiaAward Dated : 23.11.06My office has received a complaint on 17.08.2006 from Smt.R. Sellammal, against theLife Insurance Corporation of India, Divisional Office-I, Delhi, that Death Claim of LateSh. A. Raja under Policy No. 112380207 has not been settled by the Life InsuranceCorporation of India.Life Insurance Corporation of India, Delhi, Divisional Office-I, has informed vide theirletter dated 10.10.2006 that they have already paid the Death Claim for Rs. 68182/-vide their cheque No. 343338 dated 25.07.2006.In the circumstances, there is no further relief to be granted to the complainant. Thecomplaint is disposed of finally.Delhi Ombudsman CentreCase No. : LI-JP/72/05-06Smt. Santara DeviVsLife Insurance Corporation of IndiaAward Dated : 27.11.06Smt. Santara Devi made a complaint to this Forum on 25.04.2005 that Life InsuranceCorporation of India Jaipur,, Division, has not paid Death Claim under Policy No.191785035 on the Life of her husband Shri. Dev Karan Mali .Hearing of the complaint was held on 14.11.2006 Shri Ram Avtar Mali relative of thecomplainant attended the hearing. Shri N.L. Moondra, Manager (claims) Life InsuranceCorporation of India , Jaipur, attended the hearing as official representative.Life Assured Late Shri. Dev Karan Mali, purchased Insurance Policy for Sum Assuredof Rs. 25000/-. The policy commenced with effect from 28.03.2000. Insurance Policy

was revived on 08.09.2003.Life Assured expired due to brain stroke on 09.09.2003 atSaudi Arabia. Life Assured was not present in India on 08.09.2003 when the policy wasrevived and his signatures on the Declaration of Good Health were found forged by theHand Writing Expert. Life Insurance Corporation of India vide their letter dated02.12.2004 repudiated Death Claim on the ground that Life Assured was not present inIndia and was abroad as on 08.08.2003 which is date of Declaration of Good Healthand date of revival. Policy was revived with fraudulent intention by making forgedsignature of the deceased Life Assured on Declaration of Good Health.I phold the decision of Life Insurance Corporation of India vide their letter Ref No.claim/D/Rep/48/191785035 dated 02.12.2004 Ref NO: claim/D/rep./48/191785035,repudiating the Death Claim.Complaint is disposed of.Delhi Ombudsman CentreCase No. : LI-DL-I/214/04-05Shri Satish ChandVsLife Insurance Corporation of IndiaAward Dated : 29.12.06My office has received a complaint from Shri Satish Chand on 10.09.2004 against LifeInsurance Corporation of India, Divisional Office -I, Delhi, regarding the adjustment ofpremiums under policy No. 112417761.During the hearing on 27.12.2006 the complainant Shri Satish Chand was absent andthe Life Insurance Corporation of India, Divisional Office -I, was represented by Smt.Santosh Bakshi Manager (PS/SSS), Sh. R.K. Premi A.O(SSS) and Ms. Renu F. SethiA.O. (PS/Claims). The representatives of Life Insurance Corporation of India hasconfirmed vide their letter dated 23.12.2006 that the Death claim has been settled bythem vide their cheque No. 271460 dated 19.7.2006 for Rs. 69065/-. The SurvivalBenefit, which was due on 28.3.2004, has also been paid vide cheque No. 272266dated 23.8.2006 for Rs. 10000/- favoring Smt. Maya Devi (Nominee of Late Shri SatishChand). The Life Insurance Corporation of India has also paid the penal interest ondelayed payment of Survival Benefit vide cheque No. 275753 dated 23.12.2006 for Rs.1860/-There is no further relief to be granted to the complainant.The complaint is disposed.Delhi Ombudsman CentreCase No. : LI-DL-I/285/04-05Shri Devender KumarVsLife Insurance Corporation of IndiaAward Dated : 29.12.06My office has received a complaint from Shri Devender Kumar on 1.11.2004 that LifeInsurance Corporation of India, Divisional Office-I, Delhi, has not settled the DeathClaim under Policy No. 120575564.During the hearing on 27.12.2006 the complainant Shri. Devender Kumar was notpresent and Life Insurance Corporation of India was represented by Ms. RanjanaKumar Manager(claims), Sh. Rakesh Bajaj A.O(claims), Ms. Renu Fotedar A.O(claims).

The representative from Life Insurance Corporation of India, confirmed vide their letterdated 22.12.2006 that the Death Claim has been settled and a sum of Rs. 107600/- hasbeen paid vide cheque No. 275707 dated 22.12.2006. This claim cheque was handedover to the complainant personally on 22.12.2006There is no further relief to be granted to the complainant.The complaint is disposed.Delhi Ombudsman CentreCase No. : LI-ICICI - 107/06Smt. Nathi BaiVsICICI Prudential Life Insurance Co. Ltd.Award Dated : 29.12.06My office has received a complaint on 20.10.2006 from Smt. Nathi Bai against theICICI Prudential Life Insurance Co. Ltd., that Death Claim of Late Sh. Bahadur Singhunder Policy No. 02357482 has not been settled by the ICICI Prudential Life InsuranceCo. Ltd.ICICI Prudential Life Insurance Co. Ltd., has informed vide their letter dated12.12.2006 that the matter of this complaint has been examined by the InternalGrievance Redressal Committee of the company and it was decided to give ex-gratiapayment of Rs. 100000 to the complainant. The complainant Smt. Nathi Bai hasaccepted the payment and has withdrawn her complaint.In the circumstances, there is no further relief to be granted to the complainant. Thecomplaint is disposed of finally.Delhi Ombudsman CentreCase No. : LI/DL-II/257/05-06Smt.Anu MahendruVsLife Insurance Corporation of IndiaAward Dated : 08.01.2007Smt. Anu Mahendru lodged a complaint with this Forum on 13.09.2005 that her latehusband Shri Atul Kumar Mahendru had taken three LIC policies No.110456368,120367153 and 120700117. The Central Office, Claim Review Committee of LIC ofIndia had repudiated the claim upholding the decision of the lower office.LIC of India, vide their letter dated 16.11.2005, informed that Shri Atul KumarMahendru had taken three policies under Table 75-20 which commenced from13.03.1987, 15.02.1994 and 15.01.1996 respectively. Sum Assured of above mentionedpolicies was Rs.25000/-, Rs.50,000/- and Rs.3,00,000/- respectively. Shri Atul KumarMahendru had died on 11.01.2004. Revival was effected on 26.06.2003 under PolicyNo.120700117. Claim was rejected due to non-disclosure of material informationregarding previous/prolonged illness of cirrhosis of Liver with Portal HTN, upper GIBleed, Esophageal varices from which he was suffering since November,2002 as isevident from claim form. The claimant herself admitted this fact in the claim form thather husband was suffering from Liver Problem since November,2002 and he receivedtreatment from Dr.J.C.Vij of Pushpawati Singhania Research Institute during the period11.04.2002 to 07.02.2003 on different dates as is evident from Discharge Summary andClaim form. Policies were revived in June 2003 without disclosing previous/prolongedillness of Life assured from which he was suffering from 04.2002. He did not disclose

this fact in his personal statement at the time of revival. Hence in terms of thedeclaration signed by the life assured at the foot of the personal statement, the revivalof the policy was declared Null and Void and as the policies in questions had acquiredpaid up value before effecting the revival, the death claim for paid up value wassettled. In view of the above facts, the case did not deserve any consideration.At the time of hearing, the representative of the complainant contested that the paid upvalue under the policies was received by J&K Bank to whom the policies were assignedand the amount of Rs.1,59,825/- was equal to the amount of loan taken from the bank.How could LIC of India decide to pay only the amount equal to the loan taken from thebank? They should have paid Rs.3.75 lakh under the policies. LIC of India contestedand produced a certificate of Dr.J.C.Vij of Pushpawati Singhania Research Institutewhich mentions that Shri Atul Kumar Mahendru was first admitted on 11.04.2002 withthe complaints of cirrhosis liver with portal Hypertension, Upper GI Bleed(Esophageal)Varices, 5 times between 04/2002 to 30.12.2003. They also produced declaration ofgood health filled in by late Shri Atul Kumar Mahendru and against question No.2wherein he had declared that he had not needed any medical attention.On examination of the papers submitted and after hearing both the parties, it isobserved that Shri Atul Kumar Mahendru as per Dr.J.C.Vij’s Certificate, has beenadmitted in Pushpawati Singhania Research Institute 5 times between 04.2002 to30.12.2003 for the treatment of cirrhosis liver with portal Hypertension, Upper GIBleed(Esophageal) Varices, which had not been disclosed by Shri Atul KumarMahendru in his declaration of good health at the time of revival of the policy. Nondisclosure of material information by him has resulted into the policies being Null andVoid and, therefore, I uphold the decision taken by LIC of India making payment only ofthe paid up value under the policies since they had run for more than 3 years from thelast unpaid premium.There is no further relief to be granted to the complainant.Complaint is disposed of finally.Delhi Ombudsman CentreCase No. : LI/DL-III/260/05-06Smt.Lajja DeviVsLife Insurance Corporation of IndiaAward Dated : 31.1.2007Smt. Lajja Devi had lodged a complaint with this Forum on 10.08.2005 that herhusband late Shri Inder Singh had taken a policy No.111036549 from LIC of Indiaunder Salary Savings Scheme. He died on 24.06.2004. The cause of his death wasroad accident at Azadpur. Some unknown vehicle/person had hit him, he fell down andgot some head injury. As a result of which, he became unconscious and died in thehospital. This is as per the police report, hospital and post mortem report. Shepreferred a claim with LIC of India, they had repudiated the claim because of falsedeclaration in the proposal form under question No.11. She has declared that herhusband was hail and hearty and was working as a labourer. It was not possible forhim to discharge his duties in case he was not medically fit. Having cough and cold isnot a major illness and her husband had died as a result of accident which has nobearing on this question. She has requested the Forum to pay the claim.LIC of India, vide their letter dated 10.10.2005, had informed the Forum that late ShriInder Singh took the above policy on 10.03.2004 and died on 24.06.2004, that is, after

3 months and 14 days of taking policy. As per Post Mortem report, the cause of deathwas cerebral damage consequent upon blunt force impact to the head. In the PMR, it isalso mentioned that there is alleged history of deceased going on road when hebecame unconscious and fell down on 22.06.2004 and life assured expired duringcourse of the treatment in the hospitals.FIR also states that a person (life assured) was found unconscious on 22.06.2004. Theclaim was repudiated on the basis of non disclosure of ill health of life assured beforetaking the insurance. As per the Employer’s certificate and medical certificates, ShriInder Singh took medical leave from 16.08.2003 to 22.08.2003( 7 days) for viral feverand cough, 15.09.2003 to 25.09.2003( 10 days) for Bronchitis and 24.01.2004 to06.02.2004( 14 days) for typhoid. In this case First Premium Receipt dated 10.03.2004.Thus just within month of Shri Inder Singh, having suffered from Typhoid, life assuredtook insurance and concealed material facts of medical leave before taking insurance.This non disclosure is material as life assured would have been suffering fromweakness due to typhoid which he did not disclose, and hence he became unconsciouswhile standing on road and suffered head injury which is ultimate cause of death.At the time of hearing, Smt. Lajja Devi disclosed that her husband was employed as alabourer with Municipal Corporation of Delhi and he was hale and hearty at the time ofhis death. He could not have discharged his duties had he not been fit. The cause ofhis death is not due to illness but because of injury to head as a result of accident. Hewas treated in the hospital. They only came to know of his death after few days whenthe body was claimed by them. LIC of India has wrongly repudiated her claim.The representative of LIC of India contested that late Shri Inder Singh had availed ofmedical leaves of 31 days from 16.08.2003 to 06.02.2004 and was not enjoying goodhealth which he did not disclose in the proposal form. Had he disclosed the same, thedecision of LIC of India for issuance of the policy may have been different. On enquiryby this Forum that the death was as a result of accident and as per the contention ofLIC of India’s letter dated 10.10.2005 that since late Shri Inder Singh was sufferingfrom weakness due to Typhoid, what bearing of the same would have been since theproximate cause was accident. The representative of LIC of India was not able tosubstantiate the same. Further, the attention of the representative of LIC of India wasdrawn to the medical certificate issued by Dr. Sunil Jaiswal, New Delhi where it hasmentioned that Shri Inder Singh was suffering from Typhoid for 14 days and he waswell to resume his duties from 07.02.2004, whether any enquiry was made by LIC ofIndia, the representative of LIC of India was unable to reply to the query. However, therepresentative informed the Forum that they have rightly repudiated the claim sincethere was concealment of material information at the time of taking the insurancepolicy.After hearing both the parties and on examination of the papers submitted, it isobserved that as per the Post Mortem Report, the cause of death of Shri Inder Singh,was due to cerebral damage consequent upon blunt force impact to the head. Allinjuries are at the most and around two days in duration. LIC of India has repudiatedthe claim on account of non disclosure of material fact under question No.11 of theproposal form where late Shri Inder Singh had not disclosed the details of takingmedical leaves. Since the proximate cause of death being accident and not illness, thecontention of LIC of India in repudiating the claim is not correct.Since Shri Inder Singh was working as labourer with Municipal Corporation of India andthe policy being issued under Salary Savings Scheme, it would have been appropriateto get the details from the employer before accepting the proposal especially when theemployees are not well educated. Further, Shri Inder Singh was also declared

medically fit to resume his duties after Typhoid as per the certificate given by Dr.SunilJaiswal.I, therefore, pass the Award that Smt. Lajja Devi be paid the full sum assured alongwith accident benefit under policy No.111036549 favouring late Shri Inder Singh, asper the terms and conditions of the policy.The Award shall be implemented within 30 days of receipt of the same. The complianceof the Award shall be intimated to my office for information and record.Delhi Ombudsman CentreCase No. : LI/JD/437Shri Hapu Ram VishnoiVsLife Insurance Corporation of IndiaAward Dated : 26.02.2007Shri Hapu Ram Vishnoi has lodged a complaint with this Forum on 07.03.2005 that hislate wife Smt. Meera Devi had taken a life insurance policy No.101048092 from LifeInsurance Corporation of India. He has lodged a claim with LIC of India as Smt. MeeraDevi, the life assured, had died on 26.09.2003. LIC of India had repudiated the claimon the grounds that late Smt. Meera Devi had not disclosed in the proposal form thatshe was not keeping good health. He stated that his wife was healthy at the time ofdeclaration as he was insured at the same time. The Development Officer had madenecessary enquiries before acceptance of proposal. She was even medically examinedby the Corporation’s doctor. At the time of insurance, she had not concealed anymaterial fact and his wife was keeping good health. He has requested the Forum todirect LIC of India to pay the death claim to him as he is the nominee under the policy.LIC of India, vide their letter dated 28.03.2005, informed the Forum that Smt. MeeraDevi died due to heart failure. The Officer who has conducted the investigation, in hisreport, has declared that she was a cancer patient for the last 2-1/2 years. A certificateto this effect was obtained from Natural Health Care Centre, dated 06.01.2005 where itis declared that Smt. Meera Devi Vishnoi was admitted in the Natural Health CareCentre on 09.06.2003 and discharged on 18.06.2003. She was treated for cancer ofovaries. She had cancer of ovaries for the last 2 years. Smt. Meera Devi had submitteda proposal to LIC of India on 30.01.2003. As such, she was suffering from Cancer atthat time. She has concealed the material fact at the time of taking the policy.Accordingly, the claim was repudiated and was communicated to the nominee, ShriHapu Ram Vishnoi.At the time of hearing, the representative of LIC of India informed the Forum that oninvestigation it was found out that Smt. Meera Devi was treated at Natural Health CareCentre, Jodhpur and in her declaration submitted in the hospital, she stated that shewas suffering from cancer of ovaries for the last 2 years which was well before thecommencement of the policy. As such, they have rightly repudiated the claim.On enquiry by this Forum that on perusal of the medical report of Dr.N.Vyas dated30.01.2003 against Question No.17 (3):Do you suspect any disease of uterus, cervix or ovaries ? : NOThe representative of LIC of India informed that disease could not be identified withoutclinical/medical examination. As such there was a reply “ NO “.On examination of the papers submitted and after hearing representative of LIC ofIndia, it is observed that Smt. Meera Devi was a patient of cancer of ovaries as per theNatural Health Care Centre, Jodhpur for the last 2 years when she was admitted on

09.06.2003 and the proposal was submitted on 30.01.2003. The disease could not bedetected by the medical examiner of LIC of India since no clinical tests wereconducted. Therefore, the doctor was not able to detect the disease.Since Smt. Meera Devi has disclosed in her statement to Natural Health Care Centre,Jodhpur that she was suffering from cancer of ovaries for the last 2 years, that is,before submitting the proposal to LIC of India, there is concealment of material fact.I uphold the decision taken by LIC of India repudiating the claim of Shri Hapu RamVishnoi under the above said policy.There is no further relief to be granted to the complainant.Complaint is disposed of finally.Delhi Ombudsman CentreCase No. : LI-DL-III/04/06-07Shri Harish BansalVsLife Insurance Corporation of IndiaAward Dated : 07.03.2007Shri Harish Bansal has lodged a complaint with this Forum on 06.04.2006 that his wifeSmt. Kusum Bansal had taken a life insurance policy No.331370848 from LIC of Indiawhich was inforce at the time of her death. After filing a claim after her death, LIC ofIndia after 9 months has repudiated the same. He sees no logic for repudiating theclaim. He has requested the Forum that his case may be considered sympathetically.LIC of India, vide their letter, dated 10.05.2006, informed the Forum that PolicyNo.331370848 was issued on 31.01.2005 with date of commencement as 28.01.2005 infavour of Shri Harish Bansal and Smt. Kusum Bansal under table and term 89.20, thatis, Jeevan Sathi Plan. They have received the death intimation from Shri Harish Bansalthat Smt. Kusum Bansal had died on 20.06.2005 just after 4 months and 19 days oftaking policy due to heart attack.In the case history received from Orchid Hospital and Form No.5152 received from Dr.Arun Anand, it is stated that she was a known case of Rheumatic Arthritis andPulm.Koch’s and was taking treatment from him for the last two years for cough andcold and old arthritis. This non disclosure is material as the cause of death of lifeassured as per Orchid Hospital record is Pulm.Koch’s and Sepsis which has directnexus with the previous disease of the deceased. Therefore, they have rightlyrepudiated the claim.At the time of hearing, Shri Harish Bansal contested that his wife was medicallyexamined by Dr.S.Yadav and as per his medical report, she was not suffering from anydisease. Further, he contested that his wife died because of heart failure and notbecause of Rheumatic Arthritis. As such non disclosure of the same has no relevancewith the cause of death. His claim, therefore, should be paid.LIC of India contested that Smt. Kusum Bansal was first admitted in Orchid Hospitaland Heart Centre on 18.06.2005 at 2.10 p.m. and was discharged on 20.06.2005 andwas shifted to Kukreja Hospital and Heart Centre Private Limited and was diagnosed acase of Right sided Massive Pneumonic and Pulm.Koch. Since as per Form No.5152submitted by Dr.Arun Anand, Smt. Kusum Bansal was a patient of cough and cold andold Pulm.Coch for the last 2 years which was before the commencement of the policy,that is, 31.01.2005. The deceased life assured had not declared of her disease in theproposal form and the policy having only run for 4 months and 19 days, the claim is notpayable.

After hearing both the parties and on examination of the proposal form submitted, it isobserved that in question No.11, the life assured has mentioned as follow:-a. During the last five years did you consult aMedical Practitioner for any ailment requiringTreatment for more than a week ?NOb. Have you ever been admitted to any hospital orNursing home for general check-up, observation,Treatment or operationNOi. Have you ever received or at present availing/Undergoing medical advice, treatment orTests in connection with Hepatitis B or AIDSRelated condition ?NOFurther on examination of the death summary of Kukreja Hospital and Heart Centre, itis mentioned that the patient was shifted from Orchid Hospital and Heart Centre toKukreja Hospital and Heart Centre Private Limited and was diagnosed a case of Rightsided Massive Pneumonic and Pulm.Koch. Further, the medical form filled in byDr.Arun Anand mentioned that she was a patient of cough and cold and old Pulm.Cochfor the last 2 years which she had not declared in the proposal form. Smt. KusumBansal did not disclose that she was a patient of cough and cold and old Pulm.Coch atthe time of taking the policy, it is a material concealment and if she had declared thesame, it was for the Insurance Company to accept the proposal or not. The proposerhaving not disclosed the disease she was suffering from which resulted in her death,LIC of India has rightly repudiated the claim.I uphold the decision taken by LIC of India repudiating the claim of Shri Harish Bansal.There is no further relief to be granted to the complainant.Complaint is disposed of finally.Delhi Ombudsman CentreCase No. : LI/TATA AIG/25/06-07Smt.Yogita SapraVsTata AIG Life Insurance Company LimitedAward Dated : 29.03.2007Smt. Yogita Sapra has lodged a complaint with this Forum on 18.05.2006 that herhusband, Shri Raj Kumar Sapra, had taken a policy from Tata AIG Life InsuranceCompany Limited for Rs.1,35,000/- on 21.09.2004. He died on 05.03.2006. She hadfiled a claim with the Insurance Company and requested the Forum to get her claimsettled.The Insurance Company informed the Forum vide their letter dated 23.03.2007 thatthey had insured Shri Raj Kumar Sapra with life insurance policy on 20.09.2004 for asum assured of Rs.1,35,000/-. He had died on 05.03.2006. The cause of death wasSeptic Shock. He was diagnosed of Acute Myeloid Leukemia on 13 th August,2004.Hematological diagnosis of Leukemia was before application date. He had undergoneBone Marrow test for the same as per report dated 24.08.2004. Further, Indoor casepapers of Dr.B.R.A.Institute Rotary Cancer Hospital dated 13 th August,2004 – AcuteMyeloid Leukemia. Hematological Report from Department of Laboratory Medicine ofAll India Institute of Medical Science dated 17 th August,2004 – Acute Myeloid

Leukemia. Bone Marrow Report dated 24.08.2004 – Acute Leukemia, MorphologicallyLymphoid. Discharge summary dated 30 th Agusut,2004 – Insured was treated for AcuteLeukemia. The claim on a contestable policy was declined on the grounds of materialnon-disclosure of cancer of the uterus. Had this medical history been disclosed, theunderwriting decision would have been to decline the insurance cover.At the time of hearing also, the Insurance Company produced the proposal formwherein treatment of Acute Leukemia was not disclosed whereas he had alreadyundergone the treatment for the same and was diagnosed on 18.08.2004 that he wassuffering from Acute Myeloid Leukemia.On examination of the papers submitted, it is observed that Shri Raj Kumar Sapra hadsubmitted the proposal form on 04.09.2004 to Tata AIG Life Insurance CompanyLimited for life insurance policy and on examination of the same, it is observed that hehad not disclosed that he was under going treatment for Acute Myeloid Leukemia whichwas diagnosed on 18.08.2004. Non disclosure of material information by Shri RajKumar Sapra at the time of submitting the proposal form deprived the InsuranceCompany to underwrite the risk correctly. Therefore, they have rightly repudiated theclaim.I uphold the decision taken by Tata AIG Life Insurance Company Limited repudiatingthe claim of Smt. Yogita Sapra.There is no further relief to be granted to the complainant.Complaint is disposed of finally.Guwahati Ombudsman CentreCase No. : 24/01/022/L/06-07/GHYSmt Shima ShyamVsLife Insurance Corporation of IndiaAward Dated : 03.11.2006FACTSInitially subject matter of the complaint was that the death-claims in 3 (three) policiesin question purchased by Late Ashish Shyam, the husband of the complainant have notbeen settled by the LIC in spite of reminders. During pendency of the complaint, 2(two) out of the aforesaid policies have since been settled and only policy no.492857691 (Sum Assured Rs.62,500/-) has remained not-settled and later repudiated.The contention of the L.I.C., vide letter dated 12/10/2006 addressed to us, on the otherhand is that death-claim under policy no: 492857691 is repudiated as it was foundduring investigation that material informations regarding health of the D.L.A. (deceasedlife assured) was suppressed by him while submitting the proposal for insurance etc.Decisions & ReasonsIt is submitted by the LIC that D.O.C. of policy no.492857691 is 28/03/04. That fromthe leave record of the D.L.A it was found that D.L.A. was an employee of ASEB andinvestigation had revealed that he availed earned leave on medical ground for severaldays w.e.f. 01/04/03 till 25/01/04. That the enquiry report submitted by BranchManager (i/c), also corroborates the fact that D.L.A was absent from duty onmedical/health ground and had undergone treatment in Christian Medical CollegeHospital, Vellore, in addition to treatment under local doctors and Dr. S.B. Das ofInternational Hospital, Guwahati.

Copy of the proposal form forwarded to us would show that the proposal was signed bythe D.L.A on 28th March, ’04 and it was submitted under B.O.C. no.13398 dated31/03/04 paying instalment of premium as Rs.250x2=Rs.500.00 under ‘SSS’ mode.Prescription dtd. 5/1/2006 by Dr. M.L. Bhattacharjee states that Ashish Shyam wassuffering from chest pain on 15/07/2003 i.e., about a year back from D.O.C., and headvised him to attend S.M.C.H. (Silchar Medical College Hospital) for furtherinvestigation. Dr. S.B. Das certified, vide letter dated 20th April, ’03, that AshishShyam was suffering from Hemorrhagic Pleural Effusion and was under his treatmentsince 01/04/2003. Similar certificates were issued by Dr. Das subsequently on 11thMay, ’03, 22nd July, ’03, 27th October, ’03. Therefore, the opposite party/ LIC hasadduced sufficient evidence in support of its contention that on and from 01/04/2003,the DLA had undergone treatment for serious illness. It appears that the presentproposal was submitted much later on 28/03/04 by suppressing the ailment and thetreatment undergone w.e.f. 01/04/03 and entries in column no.11 of the proposal formwere made denying these facts which amounts to suppression of material facts, thedisclosure of which might have led the insurer to take a different decision in theunderwriting other than what was taken at that time.In view of the facts aforesaid, we are of the opinion that there is nothing to interferewith the act of repudiation of the death-claim preferred under policy no.492857691. Wehave already observed that other two policies referred by the complainant have alreadybeen settled by making payments of the requisite amounts etc.In view of discussions and findings as aforesaid, there is no ground to interfere andaccordingly matter stands closed.Guwahati Ombudsman CentreCase No. : 24/01/077/L/06-07/GHY.Smt Alomara Begum MazumderVsLife Insurance Corporation of IndiaAward Dated : 10.11.2006Facts (Statements and counter statements of the parties) :The grievance of the complainant is that the death-claims under the two policies inreference were wrongly repudiated by the insurer on the pretext that the policies werein lapsed condition on the death of the insured.On the other hand, the view expressed by the insurer / LIC is that the policies inquestion were revived on 30/09/03 on the strength of D.G.H. (Declaration of GoodHealth) by paying the arrears of premia for two years six months. That while submittingthe D.G.H., the D.L.A. (Deceased Life Assured) stated that his health was ‘good’, buthis leave documents and relevant papers procured will show that he was suffering fromdisease like PUS, Hepatitis etc. prior to prayer for revival of the policy.Decisions & ReasonsThe copy of leave certificate, medical certificate and a fitness certificate procured fromExecutive Engineer (PWD), the employer of the D.L.A., will clearly show that he wassuffering from P.U.S. (Peptic Ulcer Syndrome) with hepatitis and were treated bydoctor for the diseases and advised the D.L.A. to take rest at least for a month w.e.f.30/09/03. That would show that D.L.A. was suffering from ailments next before30/09/03. He was given fitness certificate to join duty w.e.f. 29/10/03. But the copies ofD.G.H. forwarded by the insurer will show that declaration was made on 30thSeptember, ’03 answering the queries regarding health condition in ‘negative’

Thus, he withheld facts and was guilty of not discharging utmost good faith while in hisattempt to revive the lapsed policy.It is also significant to note that the premium for two years six months were paid on30/09/03 along with D.G.H. It might have been done in utmost desperation anticipatingfuture insecurities etc.Concluding, we find no ground to interfere with the act of repudiation but consideringthe financial status and family condition of the D.L.A. we recommend an ex-gratia reliefof Rs.20,000/- on the strength of Rule 18 of the R.P.G. Rules, 1998.It is hereby directed that the insurer will settle the claim on the basis of the abovediscussions and decisions.Guwahati Ombudsman CentreCase No. : 24/02/054/L/06-07/GHYSmt. Juri Kakati SaikiaVsSBI Life Insurance Co. Ltd.Award Dated : 10.11.2006GrievanceSmt. Juri Kakati Saikia is the complainant. She states that her husband late PradipSaikia procured SBI-Life Insurance Policy (under scheme Sudhrashan Plan-B) assuringsum assured of Rs.50,000/-, risk date being 08/03/2004 and used to deposit premiathrough company’s authorized insurance adviser, Mr. Prafulla Borah. The saidpolicyholder died in a motor accident on 12/07/05 leaving herself and one minor son aslegal heirs. She registered her death-claim with the insurer but the same has not beensettled notwithstanding her efforts and approaches for the purpose. That all premia/renewal premia were being paid to company through insurance adviser Prafulla Borah,who used to collect the same by issuing ‘acknowledgement receipts’ in printed form inthe name of the company. The relief sought is Rs.1,00,000/- (sum assured Rs.50,000/-+ accident benefit of Rs.50,000/-) along with any other relief to which she may beentitled .ReplyThe insurer by a ‘self-contained note’ submitted that premium due for quarter startingJune 08, 2005 remained unpaid on the date of the death of the D.L.A. because thecheque no.897312 was drawn on account of the insurance adviser Prafulla Borah andnot on the bank account of the policyholder and as per rules of the company, a thirdparty cheque cannot be accepted for proposal deposit and for payment of policypremium and accordingly, the claim was rejected.DECISIONS & REASONSWe have perused the documents and considered the views expressed by the parties.The complainant has enclosed the policy copy and other connected terms andconditions of the policy. There is nothing to show the mode of payment of premia asclaimed by the insurer, rather the receipts issued by the insurer will show that all thepremia were collected by the insurance company through the insurance adviser,Prafulla Borah and Prafulla Borah also used to issue acknowledgement of receipts ofpremia (received from the insured) upon the SBI-Life Insurance printed forms. There isnothing to show any refusal to accept the premia so tendered through cheques/draftsby the insurance adviser. The premium receipt no.25556 dtd. 3rd August, ’05 hasclearly mentioned that the premium had been received by cheque no. 897312 (dated15/06/05) and accepted by the insurer. Renewal premium due on 8/3/05 and 8/6/05 was

eceived by insurance adviser Sri Borah on 28/05/05, i.e., even earlier than the duedate in case of due date of 8/6/05 and deposited with insurer by 15/6/05. Thephotocopy of the counterfoil of cheque has also been filed. Thus, we don’t findanything from the documents forwarded to us by the insurer to substantiate the pleathat cheques drawn on other’s account / third party account were not acceptable to theinsurer. Interestingly, other premia paid on behalf of the insured by demand drafts wereaccepted. Even the cheque no. 897312 dated 15.06.05 was not returned by the insurereither to the insurance adviser or to the insured with endorsement that such payment isnot acceptable. Rather, receipt was issued belatedly on 3rd August, ’05 by acceptingthe premium. Therefore, we find the objection raised is ‘an objection for objection’ssake’ and has not been substantiated by appropriate policy conditions to carry out anymeaning. Incidentally, it may be remembered that there is no question of fraud beingpractised as the insured died unfortunately in a motor accident on 12-07-05 afterdeposit of the premium with the advisor for necessary regularization of payment ofpremium with the insurer and it was accepted issuing receipt after his (insured) death.Therefore, we don’t agree with the decision of the insurer that the policy in questionwas in lapsed condition on the date of death of the insured.It is hereby directed that the amount due to the insured is to be paid by the insurer tothe claimant together with penal simple interest @ 6% p.a. w.e.f. 13-02-06 .Guwahati Ombudsman CentreCase No. : 21/01/079/L/06-07/GHYMr. Lamhao DoungelVsLife Insurance Corporation of IndiaAward Dated : 15.11.2006Brief Facts leading to complaintBriefly stated, the grievance of the complainant is that death-claims lodged by him withthe LICI due to death of his father in connection with two policies were repudiatedimproperly on the pretext that the D.L.A.(deceased life assured) made incorrectstatements and withheld correct informations from them regarding his health at thetime of effecting the insurance etc.Opponent’s viewsThe submission of the insurer is that it was revealed during enquiry of the death-claimsin question that the D.L.A. had been suffering from malaria-fever, gastritis andrespiratory tract infection, amoebiasis during the period of four years prior to his death.But these facts were not disclosed by the D.L.A. at the time of taking these two policiesfor which there was suppression of facts with fraudulent intentions to procure the twohigh risk policies.DECISIONS & REASONSIt appears that the doctor who treated the D.L.A. issued two certificates on 21/02/05and 06/07/05. There is no dispute that in questionnaire of item no.11 of the proposalform regarding ‘Personal History’ the answers were in ‘negative’ by the proposer/D.L.A.while submitting the proposal form, the relevant part of which is as in annexure ‘C’ tothis judgement. There is no dispute that the D.L.A. died of ‘congestive heart failure’.The medical report dated 06/07/05 is more specific and exhaustive to say why theailments for which the D.L.A. had undergone treatment were of minor nature and forshort duration. It is also there that there is no evidence of D.L.A. taking any medicalleave from his employer during his service career. Thus, if we go carefully by the

questions provided in item no.11 of the proposal form, we will find that it was notobligatory under the particular facts and circumstances of the case for the proposer tomention any ailment requiring treatment for less than one week and ailments regardingliver, stomach, heart, lung, kidney, brain or nervous system. The medical reportsprocured by the insurer do not mention attack on any such vital organ of the bodyexcepting one or two. But then, such minor disease of stomach or digestive system,viz., amoebiasis, gastritis may be overlooked and one may not remember such ailmentsparticularly when the ailments were of very short duration and not of serious nature.Therefore, we are of the humble opinion that it will be too technical interpretation ofthe proposal clauses/conditions regarding ‘Personal History’ to find and hold that therewas any case of withholding correct/material informations regarding health at the timeof effecting the insurance in order to invite serious action like the repudiation of deathclaimwhich is otherwise valid. The complainant has rightly submitted that there was nomalafide intention in filling up the proposal form and ‘all the questions were answeredhonestly and innocently on good faith’. We agree with the submissions of thecomplainant that under the particular facts and circumstances of these claims, theclaims repudiations were not justified and are liable to be set aside, which we do.It is hereby directed that the insurer will re-open and review the death-claims and takeappropriate decision for payment of the just claim due to the complainant as per theterms and conditions of the policy.Guwahati Ombudsman CentreCase No. : 24/01/003/L/06-07/GHYSri Ramesh SharmaVsLife Insurance Corporation of IndiaAward Dated : 28.11.2006Facts (Statements and counter statements of the parties) :One Sri Ramesh Sharma is the complainant. He states that his father DewchandSharma (DLA) purchased a policy from LIC, Tinsukia Branch, sum assured beingRs.45,000/- under New Jana Raksha Policy and died on 2/01/05 at Galimpur, P.O.Tariya, Dist. Saran (Chhapara), Bihar. The death claim was lodged but no settlementwas made by the LICI.The LIC has not submitted any ‘self-contained note’ although through correspondencesit is stated by Jorhat Divisional Office that it is making some enquiries like verificationof the age etc., from Muzaffarpur Divisional Office and branch office but till date noresponse from either side of offices has been made. A subsequent letter from theManager (Claims) of Jorhat Divisional Office states that the enquiry report has beenreceived by it and the matter is under process.Decisions & ReasonsIt may be noted that on registration of the complaint on 12/04/06 we have alreadyconsumed a period of over 7 months to come to a decision but failed due to non-cooperationof LIC Division concerned. It may be noted that age factor by itself, will notcreate much hindrance in settling the claim if the adjustment of premium is made asper the LIC policy conditions. We are constrained to observe that D.O., Jorhat is nottaking the matter seriously to resolve the issue quickly and efficiently but trying to dragthe matter on unacceptable grounds, making it difficult for us to dispose etc. the matterwithin 3 months as stipulated by R.P.G., 1998.In view of the discussion aforesaid, it is hereby directed that LIC will take up the matterin right earnest and settle the death-claim within next 30 days from the date of receipt

of award/order under intimation to this Authority. However, if dis-satisfied, thecomplainant may approach here again.The LIC is further directed to consider payment of penal interest for any unusual delayin resolving the problem and making payment etc., as the case may be.Guwahati Ombudsman CentreCase No. : 24/01/005/L/06-07/GHYSmt. Rakhi PaulVsLife Insurance Corporation of IndiaAward Dated : 01.12.2006Facts (Statements and counter statements of the parties)The complainant Smt. Rakhi Paul states that the death-claim preferred by her inconnection with the policy in question has not been settled by the LIC.By letter dated 16/05/06 addressed to us the Manager (Claims) of LIC Divisional Office,Guwahati, stated that sum assured in this context was Rs.1,25,000/- under table andterm 103-20 on the life of Sujit Kr. Paul, D.L.A. (Deceased Life Assured) , mode ofpremium being ‘yly’. That at the death of the D.L.A. on 23/06/04, the policy was ofduration of 2 months 25 days. That as per the report of the I.O., the D.L.A. had beensuffering for 3 to 4 months prior to the death vis-à-vis the policy duration of 2 months25 days only. That the D.L.A. expired in the Dr. B. Borooah Cancer Institute, Guwahation 23/06/04 as per the statement of the claimant, but space for answers to questionscontained in claim form ‘B’ was left blank with a throughout remark ‘does not arise’ byauthority of Dr. B. Borooah Cancer Institute, Guwahati and accordingly, forclarification, it (LIC) wrote to the complainant/claimant for sending treatmentparticulars from 16/6/04 to 23/06/04 along with the case history. But the complainantdid not comply with the request till date of that letter dated 16/05/06.Decisions & ReasonsThe copy of claim form-‘A’ forwarded to us mentions that the duration of the last illnessof the D.L.A. was 7 days w.e.f. 15/06/2004 causing his death on 23/06/04 due to‘cardio respiratory failure’ and the D.L.A. complained of ill health (heart pain) on16/06/2004. It was rightly pointed by the concerned officer of the LIC that certificate ofhospital treatment, claim form ‘B’, issued by the Senior Resident of Dr. B. BorooahCancer Institute, Guwahati, has filled-up the form without any particulars simplymentioning ‘does not arise’. The medical attendants certificate, claim form ‘B’ alsomentions that the patient complained of heart pain and the duration of the same wasfor7 days w.e.f. 16/06/04. Interestingly, the certificate of identity and burial or cremation(claim form ‘C’) is signed by Residental Surgeon of Dr. B. Borooah Cancer Institute,Guwahati, mentioning that he saw the patient alive on 23/06/2004 and patient on deathwas cremated on 23/06/2004 at Lanka Muktighat (after his death at Dr. B. BorooahCancer Institute, Guwahati on 23/06/04 at 2.40 p.m). The photocopy of the certificatedated 19/03/05 from Dr. B. N. Mondal, Lanka forwarded here by the complainant showsthat said doctor treated D.L.A. Sujit Kr Paul on 29/05/04 for fever, headache andbodyache but treatment was not responding and he referred the D.L.A. to specialist on07/06/04 (there is no document to show that the D.L.A. was referred to the Dr. B.Borooah Cancer Institute, Guwahati by said Dr. Mondal).In her subsequent letter dated 10/07/06, the complainant Smt. Rakhi Paul has averredthat her husband (D.L.A.) was holder of seven number of policies and she received all

the claims excepting the present one. In the same letter, she further states that theD.L.A. was taken to Dr. B. Borooah Cancer Institute, Guwahati on 23/06/04 fortreatment and he died there due to heart failure just within one hour of arrival there forwhich formal admission and treatment was not possible. This will clearly contradictearlier statements of her in the contents of certificate of identity and burial/cremation,medical attendants certificate, claimant’s statement and certificate of hospitaltreatment etc., mentioned beforehand. Therefore, we find that there is no consistencyin the statements of the complainant. Moreover, she has not complied with the requestof sending treatment particulars of the D.L.A. from 16/06/04 to 28/06/04 as requestedby the Manager (Claims) of LIC vide his letter dated 21/illegible/06.Concluding, we find no convincing ground has been shown by the complainant for theinterference of the Ombudsman at this stage and the matter stands closed, for the timebeing, with these observations with a further direction to the LIC to take appropriatedecision in this case as it thinks fit and proper, provided the complainant furnishes thedesired informations.Guwahati Ombudsman CentreCase No. : 24/01/006/L/06-07/GHYMd. Nurul Islam AliVsLife Insurance Corporation of IndiaAward Dated 07.12.2006GrievanceThe claimant here is the nominee of the deceased life assured (D.L.A.), his mother. Hisgrievance is that on the death of his mother on 04/02/04, he lodged the death-claimand submitted all necessary filled-up forms but the insurer/LIC was not settling theclaim.Reply from LICIThe views expressed by the LIC, vide copy of the letter addressed to the complainantand the photocopy of the ‘office notes’ forwarded to us, appears to be as follows :———That the liability under policy had to be repudiated due to D.L.A. withholding materialinformations regarding her actual age while effecting the insurance cover.That she gave her age as 50 years when she signed the proposal for insurance therebyunderstated her age by 11 years because the evidence collected by the LIC revealedthat the D.L.A. was not less than 61 years of age at the time of presenting theproposal.That had she disclosed her correct age, the insurer would not have accepted herproposal etc.Finally the claim was repudiated with the observation (s) as below :-By understatement of age by about 11 years the DLA suppressed the material fact andgot the policy, for which she was not insurable with actual age at D.O.C.So,(1) The Committee recommends for Repudiation of the ClaimIssueWhether repudiation of the death-claim was justified under the facts and circumstancesof the case.Decisions & Reasons

It is quite significant to note that the policy in question, DOC-22.03.2001, was in lapsedcondition for quite a long period after the initial payment of three premiums and wasrevived only on 08/01/04 i.e., 26 days next before the death of DLA on 04/02/2004 bypayment of as many as 9 quarterly arrears of premiums w.e.f. 12/2001 to 12/2003. Theduration of the policy was 2 years 10 months 12 days in total inclusive of the revivalperiod of 26 days. As per the report of the I.O., the DLA had no income of her own. Butit appears from the proposal form that she stated her annual income as Rs.26,000/-from ‘cutting’, ‘knitting’, etc., It is also shown that her husband had a policy of sumassured of Rs.15,000/- taken on 30th January, 1987 and another of Rs.2,000/- taken inthe year 1972. But she procured the policy for sum assured of Rs.50,000/- at muchlater stage of her life in the year 2001. As per facts given under column ‘FamilyHistory’ of the proposal of her husband signed on 30-01-1987 the age of the proposerwas 53 years and age of his wife (i.e., present DLA) was 47 years and ages of childrenwere 29, 27, 24. years etc. In a policy procured by the present complainant (son of theDLA), his date of birth was shown as 20-02-1958 and age on 17-03-01 (date ofproposal) as 43 years. From this it was rightly calculated out by the insurer that underall probability, the age nearer birth of the DLA at the time of taking the present policywas 61 years. It is also stated that under table-14, the maximum age at entry is 60years. The I.O. in the enquiry report also noted that DLA had no income of her own andas per the established norms, a house-wife with no income of her own can be givenmaximum insurance equal to income of husband. The certificate issued by Gaobura on27/08/2006 shows that the DLA was having handloom and broiler farm business. If it istaken to be true then it contradicts the statement of the DLA in the proposal form whereshe stated she has having business of ‘cutting and knitting’.Thirdly, the LIC has procured information from the Headmaster of No.2 Dobok LPSchool. The copy of letter says that there is no record of any certificate being issued infavour of Ms Loufuli Begam, daughter of Alicha Ali. Ali of No.2 Dobok on 1/3/1965.Therefore, it is likely that age verification certificate was a fraudulent documentproduced while submitting the proposal. From the copies of the ‘notes and decision’ ofthe policy docket, it appears that all the relevant factors were considered by the‘standing committee’ of the insurer and there is no infirmity in the decision so arrivedat while repudiating the claim. It has been rightly submitted by the insurer that at theage of 61, the DLA was of uninsurable age and could not have taken the policyaforesaid for sum assured of Rs.50,000/-.Concluding, in the background of the discussions aforesaid, we find no infirmity in thedecision taken by the LIC/insurer and accordingly, in our view there is no scope for anyinterference from this authority.In view of the discussions and findings aforesaid, the complaint stands closed.Guwahati Ombudsman CentreCase No. : 21/01/047/L/06-07/GHYSmt. Kiran SaikiaVsLife Insurance Corporation of IndiaAward Dated : 08.12.2006Facts leading to grievance of complainantIn brief, the grievance of the complainant is that on the death of her husband , thepolicyholder, she lodged the death-claim but no settlement has been done till date.Counter-statements from opp.party/insurer

The submission of LIC is that the policy was in the lapsed condition due to nonpaymentof premium due 2/2005. That the premium due 1/05 was adjusted on 31/3/05but three numbers of MLY premiums due 2/2005, 3/2005 and 4/2005, were not paidbefore the death taking place on 8/5/2005. That the claim is not payable because thepolicy was lapsed and that although it was a ‘SSS’ policy, the DLA was bound to paythe premiums in view of the fact that DLA signed on Annexure-I(A) & Annexure II (A) ofthe policy which makes it mandatory (although under SSS) for the insured to makepayment of the premium due in case there was no deduction from monthly salary etc.Decisions & ReasonsSo, the terms and conditions aforesaid clearly debars the insured (DLA) to claim reliefif there is any non-payment of the premium by the employer unless and until in suchdefault he himself has paid the premium to keep the policy in running condition.Be that as it may, the policy in question was in running condition for more than one anda half year and the insured died due to sudden heart attack leaving behind his wife andcollege-going children. We think some ex-gratia relief may be given to the familymember of the DLA to overcome the sudden financial distress, particularly, in view ofthe fact that reasons for non-payment of the premium was due to non-availability of thesalary of the DLA and circumstances beyond his control.In view of findings and discussions as aforesaid in exercise of powers under Rule 18 ofR.P.G. Rules, 1998 I hereby direct that 50% of the sum assured may be paid to thenominee of the DLA/claimant.Guwahati Ombudsman CentreCase No. : 21/01/072/L/06-07/GHYSmt. Lakhimi DuttaVsLife Insurance Corporation of IndiaAward Dated : 19.12.2006FactsDeath-claims under the above-mentioned two policies were repudiated by the insurer,hence this complaint.The insurer would submits that Deceased Life Assured (DLA) had been suffering fromJaundice/Hepatitis before the date of commencement of the above-noted polices andthere is evidence of his availing leave for 79 days w.e.f. 01/10/2002 till 20/12/02. Thatthe DLA did not disclose his ailments while filling-up the proposal forms at the relevantplace. That he gave false answers to questions in item no.11 of the proposal forms andaccordingly, as per terms and conditions of the contract, the claim under the aforesaidpolicies were repudiated.Decisions & ReasonsIt will be seen that the DOCs in both the cases were 8/5/03 and duration of the policies5 months 27 days. LIC collected certificate from Dr. P.C. Saikia which has certified thatDLA was victim of ailment of Jaundice c infects hepatitis from 01-10-02 to 21-10-02..There is also a discharge certificate issued by Srishti Hospitals & Research Centre (P)Ltd., Paltan Bazar, Dibrugarh showing admission of the DLA on 04/03/03 for ‘FUC ofRTA with Ethanol dependence’. The certificate issued by Dy. Director, Food & CivilSupplies, Dibrugarh, shows that the DLA availed earned leave on medical ground from01/10/2002 to 20/12/2002. The enquiry report of the ABM(S), Jorhat DO, has clearlyindicated that the DLA was not in good health at the time of proposal and the claim isnot at all genuine. In connection with both the proposals, the answers of the proposer

were ‘negative’. and answer to the question ‘what has been your usual state of health?’ was stated ‘Good’. Thus, we find that there was a clear case of violation of utmostgood faith’ (Uberimma Fide) and accordingly, there is nothing wrong in the decision ofrepudiation recorded by theLIC Branch/Division concerned. The certificate of hospital treatment and MedicalAttendant’s Certificate issued in this context are indicative of the fact that death wasdirectly resulted from the complications of Jaundice/Hepatitis which was concealedwhile presenting the proposals for the aforesaid policies in question.In the result and on the basis of the discussions aforesaid, we find that there is nothingwrong in the act of repudiation recorded by the LIC and as such there is nothing tointerfere. The matter stands closed accordingly.Guwahati Ombudsman CentreCase No. : 21/01/053/L/06-07/GHYSri Bimal MurahVsLife Insurance Corporation of IndiaAward Dated : 18.12.2006Facts leading to grievance of complainantThe view of the complainant is that his father late Thaneswar Murah, the life assured(L.A.) purchased the policy in question during his lifetime and expired on 25/05/03.That death-claim was lodged with LICI but the claim was repudiated on the plea thatthe Deceased Life Assured (DLA) died of Carcinoma Oesophagus after suffering fortwo years before death and accordingly, nothing was payable.Counter-statements from opp.party/insurerThe view expressed by the insurance company is that DLA was suffering fromCarcinoma Oesophagus before date of commencement of the policy in question andno-disclosure of the said fact was made in the proposal/personal statement rather DLAhad given false answers to all the items under question no.11 of the proposal form andaccordingly, as per the terms and conditions of the policy the claim had to berepudiated.Decisions & ReasonsThere is no dispute that the DLA died of the disease of Carcinoma Oesophagus and insupport thereof the complainant also submitted medical record from Dr. BhubaneswarBorooah Cancer Institute. The connected proposal form shows that the policy inquestion, sum assured Rs.50,000/-, was issued consequent to proposal submitted on26th July, ’02 and all the queries made under question no.11 (personal history),excepting question regarding health condition No. 11 (i), were answered in ‘negative’stating therein in question no.11 (i) that the health condition of the proposer was‘Good’ at the time of taking the policy (DOC : 20/08/02). The certificate obtained fromemployer of the DLA states that the DLA was absent from duty w.e.f. 28/02/98 till20/08/02 and the Doctor-in-charge of Dr. Bhubaneswar Borooah Cancer Institute hassubmitted a report in Form No.5152 stating thereupon that the DLA was suffering fromCarcinoma Oesophagus for the last 2 years and he was consulted for the first time on23rd April, 2003 with symptom of difficulty in swallowing and was treated from 23/04/03till 05/05/03 which will mean that DLA was suffering from cancer on and from a datemuch earlier to DOC of the present policy which policy continued for 9 months 5 daysonly till the death of the DLA. Incidentally, it appears from the papers submitted by the

LIC that other two policies of Sum Assured Rs.75,000/- and Rs.2,00,000/- have beenadmitted and paid.Thus, we are of the opinion that there is no scope for any interference from thisAuthority with the decision of repudiation of the death-claim and accordingly, thecomplaint has no force and stands closed.Guwahati Ombudsman CentreCase No. : 21/01/110/L/06-07/GHY.Mrs. Indira GogoiVsLife Insurance Corporation of IndiaAward Dated : 29.01.2007Facts leading to grievance of complainantThe grievance of the complainant (wife of policyholder) is against repudiation of deathclaimsin connection with the policies mentioned above. The LICI repudiated the claimson the ground of withholding material informations/suppressing material facts whilesubmitting the concerned proposal forms. The complainant contends that the DeceasedLife Assured (DLA) discharged his duties without any absence while under employmentand she is financially hard-pressed on the death of the DLA and hence sought for reliefetc.Counter statements from Opp.party/InsurerThe insurer/LICI, on the other hand, would submit that DLA had suffered from variousailments like convulsive disorder, malaena, Bacillary Dysentery and in this connectionhe availed sick leave from 09.04.98 to 15.05.98, 30.8.99 to 15.09.99, 26.08.01 to06.09.01 on different occasions. That the DLA failed to disclose these facts of availingsick leaves while submitting the proposal/personal statement and accordingly wasguilty of deliberate mis-statement therein and hence the claim had to be repudiated asper the terms and conditions of the contract.Decisions & ReasonsUndisputedly, the cause of death was Cardio Respiratory Failure resulting from‘extensive ….parenchymal hematoma with mass effect & ventricular extension’. In thecase summary issued by G.M. Hospital (P) Ltd., Dibrugarh on 31/10/03, it is stated thatthe DLA was admitted on 13/09/03 with ‘history of sustained head injury on 12/09/03 at12 PM’ and on examination he was found to have sustained right elbow abrasion, rightscalp contusion on parietal region etc. In the certificate of hospital treatment (formno.3816/Claim Form-B) it is stated that the DLA was admitted with complaint ofunconsciousness following head injury. As per entry in item no. 33 of the Claim EnquiryReport , the ABM (S), LICI, Naharkatia, it is stated that Enquiry Officer couldunderstand from the enquiry that the DLA fell down when he was purchasing his dailyessential commodities. It was also found by the Enquiry Officer that the DLA sufferedfrom other ailments before DOC and availed sick leaves during his service period. So,the stated injury sustained on head by DLA is not from ‘external visible means’ but dueinternal physical disorder (may be convulsive disorder) with which the DLA used tosuffer next before the purchase of policies in question.The LICI could collect informations from the employer of DLA to submit that the DLAavailed sick leave as follows :-9-4-98 to 15-5-98 – (37 days) Convulsive disorder.30-8-99 to 15-9-99 – (17 days) Malaena26-8-01 to 6-9-01 – (13 days) Bacillary Dysentery.

Therefore, the view taken by the LICI as per the ‘official note’ prepared that the DLAsustained head injury caused by sudden fall due to convulsive disorder has substance.It is also established by the documents produced by the LICI that DLA was an ailingperson before DOC of the policy but there was no mention of these sufferings ordiseases in the connected part of the proposal forms submitted by DLA.Unfortunately, the proposal forms disclose that all the questions regarding ‘PersonalHistory’ were answered in negative (excepting one where the state of health has beenmentioned as ‘Good’), refer answer to question no.11 of the proposal forms. Healthcondition is an important material for the insurer to take decision in the underwritingand accordingly, it has got serious implications for which any omission or commissiontherein cannot be overlooked. Convulsion as per medical dictionary is a violentinvoluntary contraction or series of contractions of the voluntary muscles and disorderis a derangement or abnormality of function etc. Therefore, convulsion disorder is aserious disease and needs to be mentioned in order to know the actual health conditionof the proposer at or during time of submission of proposal for procurement of policy.In this context, we find that during a service career the DLA availed both privilegeleaves and sick leaves and sometimes extending over 37 days. (from 9/4/98 to 15/5/98due to convulsive disorder).We also observe that the policy duration in these cases were 2 years 8 months 18 daysand 1 year 9 months 21 days respectively procured in consecutive years of 2000 and2001, although the DLA was in service from 1997 onwards, if not from earlier period,as per available datas which contradicts the statement of the complainant in hercomplaint where it is stated that the DLA ‘discharged his duty without any absencefrom his work’. In the result, we don’t find any strong ground to interfere with thedecision arrived at by the insurer.In view of the discussions aforesaid, the matter stands closed.Guwahati Ombudsman CentreCase No. : 21/01/076/L/06-07/GHY.Smt. Sarita AgarwallaVsLife Insurance Corporation of IndiaAward Dated : 31.01.2007Facts (Statements and counter statements of the parties)The complainant is the wife of the Deceased Life Assured (DLA) who purchased thepolicy (the particulars of which is noted above) vide proposal (DOC dated 28/02/2000)and it is stated by the complainant that the DLA died on 6th December, ’03. That theLICI issued discharge voucher for Rs.2,49,200/- in December, 2003 but thereafter isnot responding to the queries regarding the full and final settlement of the death-claimlodged.The Branch Manager of Moran Branch Office of LICI vide his letter dated 25.09.06stated that the Divisional Office Jorhat has repudiated the claim on 31/07/04 but theconnected file/record of the claim case was missing.Decisions & ReasonsCorrespondences were made unfortunately with negative results to get the selfcontainednote from the LICI. Although it is stated in the complaint that 4 yearspremiums have been paid by the DLA, in support thereof no documents or copy of thepremium receipts etc. or any other documents have been filed by the complainant. Theclear ground of repudiation is also not available from the concerned Divisional Office or

Branch Office of LICI. It is stated that the DLA died of Cardio Respiratory Failure butthe position is not clear whether before death the policy was in running conditionwithout any break or it was revived before death of DLA after any lapse in payment ofpremium. In any case, it is most unfortunate that clear picture is not coming from LICIin spite of several reminders issued from this Office. It is true that for effective disposalof the complaint, matters available are insufficient. But then, we cannot keep this casepending for unlimited period and accordingly, it is ordered as here-in-under.The Divisional Office Jorhat in consultation with the concerned Branch Office will takeup the matter/issue seriously and try to resolve the issue within 60 days from today asper the available records. It is suggested that the possibility of refund of the premiumsdeposited may be considered if other method for settlement of claim appears to be notpracticable under the particular facts and circumstances of this case.The matter stands disposed of accordingly for the time being.Guwahati Ombudsman CentreCase No. : 21/01/137/L/06-07/GHY.Smt. Urmila TalukdarVsLife Insurance Corporation of IndiaAward Dated : 12.02.2007Brief Facts leading to complaintThis is a complaint against repudiation of death-claim in connection with the policyparticulars given as above. The complainant Smt. Urmila Talukdar is the wife of theinsured Late Kanak Sen Talukdar. The complainant states that DLA (Deceased LifeAssured) died an untimely death and left behind 3(three) minor daughters and 1 (one)son and on his death they are finding it difficult to keep the body and soul together.That the reason for repudiation of the claim was neither known to the DLA nor is knownto them. That if and when the repudiation is upheld, matter may be re-considered bythis Institution on humanitarian ground etc.Opponent’s viewIn its self-contained note the insurer, through its A.O. (Claims), submits that the Policyin question did not acquire paid-up value before revival and it was revived afterpayments of premiums for two and half years. That as per evidence collected the DLAwas on leave under medical ground w.e.f. 23.08.04 to 30.09.04. That as per doctor’scertificate dated 06.09.04, the DLA was treated as outdoor patient in the GastroentrologyDepartment of Guwahati Medical College from 06.09.04 i.e., 3 days prior tothe revival, and was referred to attend Cancer Institute of Adiyar, Chennai/CMC,Vellore. That DLA did not disclose the fact of his suffering from such diseases whilesigning the DGH (Declaration of Good Health) on 09.09.2004 for revival of policy andhence the claim had to be repudiated and the order of repudiation was also upheld bythe Eastern Zonal Office of the insurer (LICI) etc.Decisions & ReasonsWe find from the Office Note etc of the insurer, (it appears) that the DLA purchasedtwo policies. One of the policy for sum assured of Rs.25,000/- was admitted forprocessing etc. But the present policy had to be repudiated as it was in lapsedcondition w.e.f. 09/2003 and was revived only on 09/09/04 signing DGH. The certificateissued by the Assam Medical College has clearly stated that the DLA was being treatedin Gastro-Enterology department of that College w.e.f. 06.09.04 as outdoor patient i.e.,

next before the date of revival of the policy. The D.G.H. was signed on 9thSeptember,’04The Medical attendant’s certificate (Form No.3784 : Claim Form ‘B’), and certificate byemployer (Form 3787; claim form ‘E’ ) have clearly mentioned that DLA startedsuffering from 04-09-04 and died of Carcinoma of gall bladder. Thus, answering thequestion aforesaid in negative was not proper and correct. The employer of the DLAhas issued a certificate stating that the DLA availed commuted leave on medicalground w.e.f. 23.08.04 to 30.09.04.Therefore, evidence collected by the insurerappears to be sufficient to establish that the policy in question was revived only afterhaving the knowledge that the DLA was suffering from serious disease like cancer etcand policy was also in lapsed condition. Therefore, revival of policy was withconcealment of material facts and it appears that repudiation of the claim under factsand circumstances as discussed, was done on the genuine grounds and there is hardlyanything to agitate against such acts of insurer.However, considering the collateral prayer of the complainant that the family has beenled to great misfortune on the death of the sole earning member, some considerationsfrom this Authority may be made to help them to come out of the sufferings to someextent. It appears that approximately, an amount of Rs.15,512/- has been deposited bythe DLA as premiums in connection with the policy in question prior to his death andLICI may not loose much if, as a special case, an amount nearer to such amount ispaid to the complainant as ex-gratia relief on the strength of provisions of Rule 18 ofthe R.P.G. Rules, 1998. This step is considered necessary by this Authority particularlyin reference to the prayer of the complainant in the last few lines of complaint that ‘incase repudiation is upheld she may be given some pecuniary relief’.In view of the discussions aforesaid, it is hereby ordered that insurer will pay a sum ofRs.20,000/- (Rupees Twenty Thousand Only) as an ex gratia relief.Guwahati Ombudsman CentreCase No. : 24/01/112/L/06-07/GHY.Smt. Dipali BhuyanVsLife Insurance Corporation of IndiaAward Dated : 01.03.2007Facts (Statements and counter statements of the parties)The grievance is for non-settlement of death-claims under the three policies despiteapproaches made by the complainant on the death of insured, her husband Late JoyBhuyan on 27.12.2004.The contentions of the insurer/LICI, inter alia, are that death claims under policy nos.480684991and 481840210 were admitted by the Competent Authority on 27.11.06 andthe Branch concerned were advised to make payments. That in regard to policy no.481841755, which was assigned to P.G. Bank, policy documents were received fromthe Bank, but on examination it was found that the claim under said policy was liable tobe repudiated by setting aside the revival as it was found on investigation that the DLA(Deceased Life Assured) was bed-ridden on the day of revival of policy and had beenunder treatment of Doctors Dr. B.N. Sarma and Dr. B. Hazarika since 01/09/2004.Accordingly, the death claim in so far the sum assured was repudiated but the heirs ofthe DLA were held to be entitled to receive the ‘paid-up value along with accruedbonus upto first unpaid premium (FUP) due on 28/03/03’ etc.Decisions & Reasons

We have considered the photocopies of the documents placed before us. Thecertificate by employer (Form No.3787/Claim Form E) stating that on 24th December,2004, the DLA complained of illness and died on 27th December, 2004 and that DLAhad availed sick leave on medical ground from 01/09/04 to 14/12/04 and again from25/12/04 till 27/12/04. The certificate issued by Dr. Hazarika says that DLA was underhis treatment from 25th December, ’04 and expired on 27th ’04 at 8.25 p.m. due tocardiac failure. It has rightly been pointed out that ‘PERSONAL STATEMENTREGARDING HEALTH’ for revival of the lapsed policy was signed by the DLA on 27thDecember, ’04 i.e., on the date of death of DLA, which can be confirmed from thephotocopy of such statement forwarded to this Office.Therefore, we find that there is nothing wrong in the decision of the insurer/LICI andsuch decision requires no interference from this Authority.Guwahati Ombudsman CentreCase No. : 21/01/160/L/06-07/GHY.Smt. M.Ibeyaima DeviVsLife Insurance Corporation of IndiaAward Dated : 20.03.2007GrievanceThe grievance of the complainant Smt. M. Ibeyaima Devi is that on the death of herhusband Shri W. Biren Singh the death-claim lodged by her has not been settled byLICI. She, being the widow of the Deceased Life Assured (DLA), has requested for reimbursement/refund of the money/amount already deposited so that it may be helpfulto her family as she has no other source of income. She has sought for intervention ofthis Authority on humanitarian ground.ReplyThe contention of the LICI , inter alia, is that the DLA revived the policy on 09/08/03 onthe basis of DGH (Declaration of Good Health) paid three quarterly premiums due from01/03 to 07/03. Thereafter, the life assured died on 11.02.04 due to Alcoholic Cirrhosiswith history of Alcoholism. He was a known Ethanolic for 10 years for which the claimhad to be repudiated by Competent Authority for suppression of facts at the time oftaking the policy as well as the at the time of revival of the policy. The order ofrepudiation was passed on 30/03/05 was duly communicated to the complainant, wifeof the DLA vide letter of the LICI dated 15.05.05.Decisions & ReasonsIt appears that total quarterly premium paid was Rs.853.00 x 14=Rs.11,942.00 and atthe time of revival three quarterly premiums amounting to Rs.2,559/- along with late feeof Rs.70.00 were paid. The copy of the proposal form shows that while filling up theproposal form in item no.11 under heading ‘Personal History’ all queries except onewere answered in ‘negative’ thereby meaning, that the usual state of health of theproposer was ‘good;’ during last five years he did not consult any Medical Practitionerfor any ailment requiring treatment for more than a week; he had never been admittedto any hospital or Nursing Home for general check up, observation, treatment oroperation; he had not remained absent from place of work on ground of illness duringthe last 5 years; he had never used and does not use alcoholic drinks and that he wasnot suffering from ailments pertaining to Liver, Heart, Lungs, Kidney, Brain or NervousSystem etc. The Discharge Summary issued by down town hospital, Guwahati hasclearly mentioned that DLA Mr. W. Biren Singh reported to hospital with a complaint of

yellowish discolourization of the eyes and swelling of abdomen for last 20 days, historyof known ethonolic for ten (10) years, and he was diagnosed to be a case of Cirrhosisof Liver with decompensation in precoma, and was managed conservatively. The dateof admission being 05/02/04 and discharged being 07/02/04. The RIM Hospital ofImphal where DLA was treated from 7/2/04 till 10/2/04 ( a day before the date of death)also issued a certificate that Shri W. Biren Singh was diagnosed as an AlcoholicCirrhosis on his admission on 08.02.04.The employer of DLA also issued a certificatestating that DLA availed 30 days earned leave on medical ground w.e.f. 28.09.02 to27.10.02 due to fracture of left leg.It is also seen that it is a policy which ran for 3 years 3 months 25 days since DOCincluding the lapse period and after revival the duration of the policy was 6 months 2days only. Thus, repudiation appears to be justified. But the complainant has alsoprayed for reliefs otherwise on humanitarian ground due to her pathetic financialcondition.Situated such, we find no ground to interfere with the decision of repudiation of theclaim on merit but are of the opinion to grant an ex-gratia relief of Rs.15,000/- on thestrength of Rule 18 of the R.P.G. Rules, 1998. The LICI may pay the same withinreasonable time with intimation to this Authority.Guwahati Ombudsman CentreCase No. : 21/01/150/L/06-07/GHYSmt. Geeta MaliVsLife Insurance Corporation of IndiaAward Dated : 29.03.2007Facts (Statements and counter statements of the parties)The complainant states that her husband expired on 13th April, 2005 and death-claimin connection with the two policies above noted were made but were repudiated by LICI(Jorhat Divisional Office). That representation to Zonal Manager was also without anypositive result. Hence this complaint.The stand taken by the LICI is that the Deceased Life Assured (DLA) had given twodifferent dates of birth, i.e., 09/06/63 and 20/04/64, in the concerned proposal forms.That LICI could procure certificate from employer of the DLA where his date of birth(DOB) has been stated as 28/06/1946 and thus, there was large difference to theextent of about 17 years or so in between the given ages and real age (collected fromemployer). That had the actual age been disclosed, the insurer would not haveaccepted his proposals and accordingly, as per terms and conditions of the policy, thedeath-claims were repudiated.Decisions & ReasonsWe have considered the views expressed by the parties and perused the documentsand noted the contents thereof. Interestingly, it appears that the policies wereaccepted by the insurance company without ‘age proof’ and now at the time when theclaims have arisen, it is demanding ‘proof of age’. The complainant has stated that dueto devastating fire her house was completely burnt down for which she is not in aposition to supply ‘age proof’ certificate. It appears that in the policies different DOBswere given and hence there was scope for the insurance company to ask forclarification to remove the doubt before accepting the proposals. Evidently which wasnot done and now, the insurance company has raised the issue after collecting acertificate from the employer where a different DOB has been mentioned.

On the circumstances aforesaid, it appears that the DLA was in the habit of beingcasual in mentioning date of birth or it may so happen that the concerned Agent put theDOB at his sweet will or never tried to verify the same or to collect authenticateddocuments regarding proof of age before forwarding the proposals for acceptance ofthe insurance company. So, it was clearly a fault on the part of the Agent of theInsurance Company or the Insurance Company itself in accepting the proposals withoutproof of age and the insurer would be debarred logically to raise the issue now in orderto repudiate the claim. It is brought to my notice that it is permissible as per the policycondition to recalculate the premiums as per the correct age at entry and theaccumulated premiums along with interest on the difference of age may be recoveredfrom the payable amount of claims. It is also brought to my notice that for both thecases in question under the mentioned plans, the DLA would have been eligible forentry, his correct age being 57 & 58 years respectively. We are of the considered viewthat repudiation of the claim on the ground shown is neither logical nor acceptable.There was perhaps no intentional suppression of age. At best it may be a confusionand inadvertent approach of both the sides for which the DLA alone cannot bepunished. At any case, it is a default on the part of the LICI not to stick to verificationof the age proof while accepting the proposal forms.In conclusion thereof, we cannot agree with the view expressed and the decisionstaken by the insurer. The act of repudiation is hereby set aside.Hyderabad Ombudsman CentreCase No. : L-21-001-0207-2006-07Sri P. Srinivasa RaoVsLife Insurance Corporation of IndiaAward dated 16.10.2006Head Notes: Complaint relating to repudiated death claim against LIC. Death due toconsumption of bathroom cleaning acid. As per claim papers, life assured sufferingfrom mental disorder at the time of revival – complaint dismissed.FACTS OF THE CASEPolicy No.64615865 was taken on the life of (Late) Smt. P. Saraswathi from CityBranch – 9, LIC, Hyderabad Division for Rs.25000/- sum assured under 91-20 (Plan &Term). The policy commenced on 28.03.2003 and it lapsed after payment of quarterlypremium due on 28.03.2004. The policy was revived under non-medical revival schemeon the strength of a Declaration of Good Health on 14.03.2005. The life assured diedon 17.07.2005 due to consumption of bathroom cleaning acid. As per the evidencecollected by LIC, the DLA was known to be suffering from mental disorder since1/2005. As per the police records, a case under Section 498 (A) of I.P.C. was bookedand subsequently the Section of Law was altered on the basis of a written statementpurportedly given by the father of DLA, stating that the DLA was a psychiatric patientfor about five years prior to death.LIC rejected the claim for reasons of suppression of material information relating to thepsychiatric problem of the DLA. The evidence produced is clear enough to uphold therejection of the claim by LIC. Hence the complaint was dismissed.Hyderabad Ombudsman CentreCase No. : L-21-001-0141-2006-07Sri Meesala GovindarajuluVs

SBI Life Insurance Co. Ltd.Award dated 20.10.2006Head Notes: Repudiation of death claim by SBI Life under Group PolicyNo.82001128307 – Conclusive proof of treatment taken prior to joining the scheme notgiven by the insurer – Hence complaint allowed.FACTS OF THE CASE(Late) Smt. Meesala Anantha Lakshmi W/o M. Govindarajulu, became a member ofGroup Life Insurance Scheme of SBI Life’s Super Suraksha Policy w.e.f. 23.07.2004.The member - life assured submitted a ‘Good Health Declaration’, at the time of joiningthe scheme and the scheme meant for the benefit of accountholders of SBI and itsmember banks. The sum assured is Rs.1 lakh for natural death. The life assured diedon 24.09.2005 allegedly due to cancer. The claim was refused by the insurer on theground that the DLA was suffering from cancer even prior to her enrolment into thescheme.The insurer produced Xerox copies of outpatient ticket no.143216 issued by KGH,Visakhpatnam. The date of consultation was not very clear on the Xerox copy. Theinsurer claimed that it refers to 14.06.2002, while the complainant claimed that thedate was 14.06.2005. The insurer could not substantiate his claim by submitting furtherevidence. Hence benefit of doubt was given in favour of the complainant and thecomplaint was allowed.Hyderabad Ombudsman CentreCase No. : L-21-002-0196-2006-07Smt. ShobhaVsSBI Life Insurance Co. Ltd.Award dated : 23.10.2006Head Notes: Repudiation of death claim under Group Super Suraksha Policy on groundof suppression of material facts – Complaint Dismissed.FACTS OF THE CASE(Late) Pratap Singh became a member of the ‘Super Suraksha’ Group Policy issued bySBI Life. The LA because a member of the scheme w.e.f. 29.1.2005 and he died on26.04.2005, reportedly due to Anasarca and Chronic Renal Failure. The life assuredbecame a member of the group policy on the strength of a ‘good health declaration’.During the course of enquires made by the insurer, it was revealed that the LA wassuffering from TB for about six years. The insurer obtained medical record from doctorswho have treated the DLA during the lifetime, who have certified about existence of TBprior to membership and about personal habits of alcoholism and smoking.Finding the declaration of good health submitted by the DLA to be false, the insurerrepudiated the claim.The evidence produced the insurer clearly showed that the LA was suffering from TBprior to membership. As the final cause of death has a bearing on the previoustreatment, the action of the insurer was upheld. In effect the complaint was dismissed.Hyderabad Ombudsman CentreCase No. : L-21-001-0218-2006-07Smt. A. SarojaVs

Life Insurance Corporation of IndiaAward dated : 26.10.2006Head Notes: Repudiation of death claim on grounds of suppression of material facts –Ex-gratia of Rs.10000/- allowed.FACTS OF THE CASEPolicy No.652502783 for Rs.100000/- was taken on the life of (late) A. Gadilingappa,R/o Kalyandurg, Andhra Pradesh. The policy commenced on 15.11.2001 under 75-20plan with quarterly premium of Rs.1730/-. The policy passed after payment of 11quarterly instalments (up to 5/2004). It was revived on 18.07.2005 on the strength of aDGH and four quarterly instalments were paid at revival time. The LA died on21.09.2005 due to kidney failure.The complainant is the nominee under the policy. LIC investigated the claim andrejected it as they found out that the LA had treatment for chronic renal failure prior torevival of the policy. They obtained a certificate from Dr. A. Gopal Rao of Rayadurgrelating to the treatment taken by the DLA prior to revival. The LA died in a hospital atBangalore on 21.09.2005 due to chronic nephropathy Syndrome. As the insurer provedin a conclusive way about existence of disease prior to revival of the policy, thecomplaint was found to be devoid of any merit. However, considering the economicstatus of the complainant, it was decided to order an ex-gratia of Rs.10000/-.Hyderabad Ombudsman CentreCase No. : L-21-001-0120-2006-07Sri B.C. BasavarajuVsLife Insurance Corporation of IndiaAward dated 29.10.2006Head Notes: Death claim repudiated by LIC for reasons of suppression of facts –complaint rejected.FACTS OF THE CASE(Late) Smt. Gowramma W/o Sri B.C. Basawaraju (Complainant) obtained a policyno.61414310 for Rs.50000/- sum assured from Madhugiri Branch of LIC, BangaloreDivision-1. The policy commenced on 20.10.2003 under Table 14 for a 15-year period.The life assured died on 15.05.2004 allegedly due to heart complaint at her residence.As the LA died in about 7 months from commencement of the policy, the insurerenquired into the merits of the case. As per their enquires the LA was under treatmentfor Diabetes Mellitus, Hypertension for about four years before issue of the policy. LICobtained F.No.5152 from Dr. Nissar Ahmed, MBBS, Chitradurga to that effect andrepudiated the claim.During the personal hearing session, the complainant did not deny treatment takenfrom the said doctor but contended that treatment was only for minor ailments. Thecomplainant further contended that BP and Sugar were at negligible levels. He furthercontended that the LA developed sudden chest paid after quarrelling with house-maidon the fateful day.The evidence produced by LIC corroborate with the past history of treatment taken forDM & HTN. Hence, repudiation action was considered to be in order and the complaintwas rejected.

Hyderabad Ombudsman CentreCase No. : L-21-001-0121-2006-07Smt. Mallavva S. JallerVsLife Insurance Corporation of IndiaAward dated 29.10.2006Head Notes: Death claim repudiated by LIC on grounds of suppression of material facts– Record of treatment prior to the commencement of policy submitted by LIC -complaint rejected.FACTS OF THE CASE(Late) Honnappa Siddappa Jaller obtained Policy No.637341548 for Rs.100000/- underTable 149-21 with a half yearly premium of Rs.2647/-. The policy commenced on28.09.2004 and the LA died on 06.04.2005 due to encephalitis. As the LA died within 6months from commencement, LIC enquired into the bonafides of the claim. As per theirenquiries the LA had taken treatment from Dr. S.C. Bangalore, MBBS for presence ofglands on the right side of neck. The obtained prescription slips given by the doctor, asper which the LA was prescribed Akurit-4 tablets for 45 days. LIC produced evidence ofconsultations on subsequent dates also from the same doctor. The insurer contendedthat the DLA was prescribed TB drugs as he was suffering from TB and AIDS. Theyobtained opinions from the DMR showing all the prescription slips obtained by them. Astheir DMR opined that the LA was under treatment for TB before commencement, theyrepudiated the claim.The evidence produced by LIC suggests treatment taken for TB. Section 45 is notapplicable and the insurer proved suppression of fact relating to treatment taken beforecommencement of the policy. Hence decision of LIC upheld and complaint was reject.Hyderabad Ombudsman CentreCase No. : L-21-001-0126-2006-07Sri SomasekharVsLife Insurance Corporation of IndiaAward dated : 07.11.2006Head Notes: Death Claims under two policies repudiated by LIC alleging suppressionof facts – Complaint rejected.FACTS OF THE CASELate Smt. Laxmamma W/o Somasekhar obtained two policies bearing no.722519725 forRs.50000/- and 722520811 for Rs.25000/- from Sriranga Patna Branch of MysoreDivision. These two policies were taken under Janaraksha Plan (91-Table) for a 20-year term. The policies commenced on 15.01.2003 & 15.02.2003 respectively with halfyearlymode of premium. The LA died on 05.02.2005 allegedly due to chest pain.As claims occurred in less than three years, LIC enquired into the merits of the case.They came to know that the LA was suffering from renal disease one year prior tocommencement of the policies and was undergoing haemodialysis for at least twoyears prior to death. Medical record relating to treatment from 12/2001 onwards wasobtained by LIC. Further there was no cross reference of previous insurance in thepolicies. LIC also found out that the LA obtained two more policies bearing

nos.722662607 for Rs.50000/- and 722622122 for Rs.50000/- from two other branches of their division. All thefour policies were secured without mentioning about other assurances. LIC alsocontended that they would not have given insurance beyond Rs.50000/-, as the LA wasa self-employed female.Based on the evidence produced relating to treatment and due to non-disclosure ofprevious policies history, the complaint was dismissed.Hyderabad Ombudsman CentreCase No. : L-21-001-0219-2006-07Smt. N. Shanta KumariVsLife Insurance Corporation of IndiaAward dated 13.11.2006Head Notes: Repudiated death claim under two policies for reason of non-disclosure ofpre-existing disease – Complaint Rejected.FACTS OF THE CASE(Late) N. Ramchandra Reddy obtained Policy Nos.691661975 for Rs.27000/- and693146366 for Rs.100000/- SA from CB-2 of Visakhapatnam Division. The policiescommenced on 14.12.2000 and 28.09.2003 respectively. Policy No.691661975 wasrevived on 23.03.2004. The LA died on 25.10.2004 due to throat cancer.As per the enquires of LIC, the LA was treated for throat cancer for about two yearsprior to the death. They obtained certificate from Lions District Cancer Treatment andResearch Centre, Visakhaptnam regarding treatment taken.The LA submitted a DGH on 23.03.2004 for revival of Policy No.691661975, in whichhe did not disclosed about treatment for cancer. The second policy also resulted intoclaim after duration of 1 year 27 days. As per claim forms B, B1certified by doctors, theLA was certified to be suffering from cancer for 2 years 8 months before death.As the policies were taken/revived without disclosure of previous illness and asconclusive proof was submitted by LIC, the complaint was dismissed.Hyderabad Ombudsman CentreCase No. : L-21-007-0148-2006-07Smt. Anuradha VijayVsMax New York Life Insurance Co.Award dated : 13.11.2006Head Notes: Repudiation of death claim alleging suppression of material information –allegation not proved beyond doubt – Complaint Allowed.FACTS OF THE CASEComplainant is the nominee under Pol.No.239183353 and is wife of the deceasedpolicyholder S.R. Vijay. The policy was taken for a sum assured of Rs.5.5 lakhs underwhole life plan with a term insurance cover for Rs. 3 lakhs. The LA died on 14.10.2005due to cirrhosis of liver with portal hypertension. The policy commenced on 01.10.2003and death of LA occurred in about two years time from commencement of the policy.

The policy was issued under medical scheme and risk accepted with an extra premiumfor elevated liver enzymes.The insurer rejected the claim stating that the LA did not disclose about history of livercirrhosis which was diagnosed way back in 3/2001.The LA was treated in Mallya Hospital at Bangalore in 03/2001 for enteric fever. Theclaim was rejected by the insurer based on the discharge summary report dated19.03.2001 given by Mallya Hospital in which the radiologist gave an impression ofcirrhosis of liver with portal hypertension. As the final cause of death was due to thesame health problem, the insurer rejected the claim.The medical reports submitted by the insurer as part of their evidence were referred toa specialist doctor at Hyderabad for expert opinion. The doctor gave an opinion thatelevated liver enzymes does not conclusively prove existence of cirrhosis of liver.However, the proposal was accepted after examination of the LA by a medical man ofthe insurer. The medical examination report contains two parts. One part of the reportwas completed by the LA and the second part by the Medical Examiner. In his part, theLA mentioned about the treatment taken in Mallya Hospital in 03/2001. The MedicalExaminer of the Insurer also made a reference to the said report. The insurer insistedof collecting the information at that time itself, chose to accept the proposal with an‘extra premium’. Allegation of the insurer is not proved beyond doubt. Hence thecomplaint was allowed.Hyderabad Ombudsman CentreCase No. : L-21-001-0249-2006-07Sri Jitendra BagadeVsLife Insurance Corporation of IndiaAward dated 15.11.2006Head Notes: Death claim rejected by LIC for reasons of incorrect information furnishedin the proposal – Rejection action upheld.FACTS OF THE CASE(Late) Maruti S/o Dattatreya Bagade obtained Pol.No.660360599 for Rs.75000/- underTable 91-20 from Gulbarga-I Branch of LIC, Raichur Division. The LA submitted aproposal dated 16.05.2005 and the policy commenced on 14.05.2005. The LA died on18.05.2005 allegedly due to chest pain. Sri Jitendra Bagade is the brother of the DLAand also the nominee.Finding the claim to occur in just 3 days from the proposal date, LIC enquired into themerits of the claim. Their enquires revealed that the LA had another policy bearingno.660888853 for Rs.100000/-. The LA’s wife Smt. Geetha was nominee under thatpolicy and death claim was settled in her favour. Particulars of old policy were notfurnished in the proposal for the current policy. As per old policy, the LA’s age wasadmitted taking DOB as 01.06.1969 on the basis of a school certificate, whereas a selfdeclarationof age was given in the current policy proposal and DOB was shown as02.04.1971. Other details relating to family history also deferred from old policy.Additionally the style of signature in both proposals deferred considerably.The insurer rejected the claim for reasons of non-disclosure of previous policy andthereby suspected the bonafides of the claim under current policy.The insurer contended that non-disclosure of previous policy made them to issuecurrent policy readily. Had they come to know about existence of another policy forRs.1 lakh, they would have enquired into the reasons for discrepancies in all material

information. The insurer also suspected fraud in taking the policy with brother asnominee. They obtained a letter from the widow of the DLA, appealing to LIC not tosettle claim to her brother-in-law.Considering the facts of the case, it was decided to uphold the repudiation action ofthe insurer.Hyderabad Ombudsman CentreCase No. : L-21-001-0268-2006-07Sri K. SankaraiahVs.Life Insurance Corporation of IndiaAward dated : 27.11.2006The complaint is about repudiation of death claim under policy no.645051198, whichwas issued by Mahabubnagar branch of LIC on the life of (late) Kurva Yellappa. Thepolicy was taken for Rs.50000 sum assured under New Janaraksha plan (91-15) andwith the commencement date of 28.3.2003. The policy was under Non-Medical schemeof the insurer. The life assured died on 3.3.2005 allegedly due to sudden heart attack.The life assured’s age was declared as 40 years at the time of proposal.LIC rejected the claim stating that the LA’s age was understated by about 10 to 15years and claimed that they would not have issued the policy under the plan had therebeen a correct disclosure of facts. LIC secured voter lists to support their contentionand they also tried to rely on the statement made by the claimant in Claim Form –Aabout age of the DLA. The insurer contended that the plan of insurance sought by theDLA is a special plan with special benefits, which are not available in other plans.Section 45 of the Insurance Act, 1938 is applicable and the insurer attributed the wrongstatement of age to a deliberate action coupled with fraudulent intent. Though theinsurer proved understatement in age, considering other factors of the case likeunattested corrections in the proposal, role of LIC agent etc., it was decided to grantan ex gratia payment of Rs.10000. The complaint was partially allowed to meet theprinciples of equity and justice.Hyderabad Ombudsman CentreCase No. : L-21-001-0305-2006-07Smt. B.K.KamalaVs.Life Insurance Corporation of IndiaAward dated 27.11.2006The complaint in this case is about repudiation of death claim under policynos.841053758 & 841054232. The policies were taken by late B.K.Kandappan on hislife for a sum assured of Rs.50000 and 100000 respectively. The first policy was takenunder Money Back plan (75-20) and the other one under Bima Kiran (T-111-27). Thepolicies commenced on 28.11.2001 with half yearly mode of premium payment. The lifeassured died on 5.7.2004. Just before death, both policies were revived on 22.6.2004and 29.6.2004 respectively. The complainant, who is the widow of the LA and also thenominee under the policies, claimed that her husband died due to sudden chest pain.The revivals were effected under non-medical scheme of LIC.As per enquiries made by LIC, the life assured died due to pulmonary TB, AIDS and notdue to sudden chest pain as claimed by the complainant. They obtained treatmentparticulars from the Government Hospital of Thoraic Medicine, Tambram, Chennai, asper which the LA was treated from 24.11.2003 to 29.12.2003. The hospital record

further revealed that the LA was readmitted into the hospital on 8.1.2004 anddischarged on 14.1.2004.There was a third spell of hospitalization from 16.3.2004 to10.6.2004 with complaints of fever, vomiting, diarrhea. The LA was treated in thehospital with anti TB drugs, retro viral therapy and he was described in the case sheetas a person living with HIV and AIDS. As the hospitalization was prior to the revival ofthe policies and as the LA did not disclose these facts in his statement of ‘GoodHealth’ submitted for revival, LIC repudiated the claims. The complainant did notdispute the evidence produced by the insurer during the personal hearing session. Asthe decision of LIC was based on facts and records, it was decided to uphold theirdecision and the complaint was dismissed.Hyderabad Ombudsman CentreCase No. : L-21-001-0299-2006-07Smt. G. SeetharatnamVs.Life Insurance Corporation of IndiaAward dated 30.11.2006The complaint is about rejection of payment of death claim under Pol. No.663421558.The policy was taken by late Garapati Abbulu for a sum assured of Rs.1,00,000 fromSindhanur Branch of LIC with the commencement date of 20.11.2004. The plan andterm are 14-14 and the annual premium was Rs.7886.00. The life assured died on12.8.2005 allegedly due to heart attack. LIC rejected the claim on the grounds that thelife assured died due to kidney failure and not due to heart attack. They claimed thatthe life assured was treated in Narayana Hrudayalaya, Bangalore from 25.10.2004 to28.10.2004 and obtained Discharge Summary from them to that effect. The casesummary revealed that the LA was admitted into the hospital for observation with ahistory of exertional dyspnoea class-I since five years, past history of hypertension andrenal problem. The LA was advised to consult a nephrologist for a regular follow upand he was also diagnosed to be having LV dysfunction of moderate to severe level atthe time of discharge from hospital. As the LA did not disclose all these material facts,LIC rejected the claim.As the claim was rejected by LIC based on well-supported hospital records, it wasdecided to uphold the rejection action. However, as the complainant made seriousallegations about the role of LIC’s Agent in submission of the proposal for the policy, itwas decided to order for refund of the first premium paid on ex gratia basis.Hyderabad Ombudsman CentreCase No. : L-21-001-0222-2006-07Smt. G.SandhyaVs.Life Insurance Corporation of IndiaAward dated 30.11.2006(Late) Thungaturty Ravindrachary, Occ. Carpenter, resident of Miryalguda obtainedpolicy bearing nos. (1) 602025517 and (2) 600487094 from Miryalguda branch of LIC.The sum assured under the first policy is Rs.5,00,000 and Rs.1,00,000 under thesecond one. The first policy commenced on 28.9.2002 and the second one on14.7.2001. The plan and term are 153-20 and 133-25 respectively. The life assureddied on 4.6.2003 allegedly due to sunstroke, while undergoing treatment in theGovernment Area hospital, Miryalguda. The nominee/complainant is the sister of thedeceased policyholder.

The claim was rejected by LIC stating that the life assured was not having adequateincome to maintain the policies, furnished incorrect family history in the proposalforms, suppressed past history of alcoholism etc. LIC obtained a certificate from MROstating that the LA was having an annual income of Rs.6000 as per 1996 data. Theyobtained a letter from the father-in-law of the DLA, as per whom the LA was having anestranged wife with no children. However, in the proposal form it was mentioned thatthe LA had two living children. In the proposal forms, the LA’s mother was shown asdead but she survived the LA. The LA was in the hospital for less than one day for histerminal illness and the doctor suspected chronic renal failure with history ofalcoholism. The complainant refuted all the allegations of LIC and maintained that theLA was healthy at the time of issue of the policy.Considering the meager income of the LA as revealed from MRO certificate, noting inthe case sheet of the hospital about past history of alcoholism, incorrect family detailsin the proposal forms, it was decided to uphold the contention of the insurer. Thecomplaint was therefore dismissed.Hyderabad Ombudsman CentreCase No. : L-21-001-0334-2006-07Sri P. Ramachandra GoudVs.Life Insurance Corporation of IndiaAward dated 30-11-2006The complainant filed a case against the decision of LIC to repudiate a death claimunder Pol. No.600648044. The policy was taken on the life of late (Smt) P. Anjammafor a sum assured of Rs.50,000 from Nizamabad branch of LIC. The policy commencedon 8.11.2004 for a five year period under endowment plan (T-14). The life assured wasaged 57 years at time of commencement of the policy and she was engaged in tailoringprofession. She died on 11.4.2005 and her husband’s claim for payment of death claimwas rejected on the grounds of suppression of material facts.The enquiries of LIC revealed that the LA died in NIMS and case sheet details revealedthat the LA was hypertensive since 10 years prior to the issue of the policy and shewas on regular medication with ‘Amlog’ medicine. As the life assured did not discloseher past history of hypertension, LIC repudiated the claim for reasons of suppression ofmaterial facts. The complainant contended that his wife was medically examined by LICbefore issuing the policy and also that hypertension is not a disease. As per the casesheet obtained from NIMS hospital, the life assured was admitted into the hospital withcomplaints of fever for ten days, petechial rash, hematuria, ITP associated withbleeding etc. Based on the evidence produced and as Section 45 is not applicable, thecomplaint was not admitted.Hyderabad Ombudsman CentreCase No. : L-21-001-0234-2006-07Smt. M.VenkataratnaluVs.Life Insurance Corporation of IndiaAward dated : 11-12-2006(Late) Mudragadda Balaiah son of M. Subbaiah; Occ. Junior Asistant, CTO Office,Guntur obtained a policy no. 672870057 for Rs.50000 from City Branch-2 of LIC,Guntur. The policy was under Asha Deep plan (121-15) with a yearly premium ofRs.4281.00. The policy commenced on 15.1.2002 and the policy was issued under

medical scheme, as the life assured was aged 46 years at the time of proposal. The lifeassured died on 7.5.2003 allegedly due to Motor Neuro disease as per claim form-Agiven by the complainant. The life assured had another policy bearing no.672338491issued in the year 2000 under Asha Deep plan and LIC settled death claim under thatpolicy. As per record of LIC under the previous policy, the DLA claim sickness benefitsunder the previous policy much before issue of the policy under dispute. The lifeassured submitted a MRI scan film and claimed that he suffered a paralytic stroke on13.12.2001. The life assured did not submit further requirements for payment of sickbenefits under the policy and he died in about six months time from the date ofparalysis. As the current policy was proposed after the alleged suffering from paralyticstroke, LIC rejected the claim on grounds of suppression of material information. Thefinal cause of death in this case is due to paralysis and there was an application in hisown handwriting from the life assured claiming Asha Deep sick benefits under aprevious policy. As the insurer produced conclusive evidence to show that the lifeassured suffered a paralytic stroke before issue of the policy, the complaint wasrejected.Hyderabad Ombudsman CentreCase No. : L-21-001-0257-2006-07Smt. K.RamulammaVs.Life Insurance Corporation of IndiaAward dated 14-12-2006The complainant is the wife of the deceased policyholder. (Late) Sri Kurva Somannaobtained policy no.652593341 for Rs.40000 sum assured under Plan 106(JeevanSurabhi) of LIC from Atmakur (K) branch. The policy commenced on 15.10.2000 andthe life assured died on 28.9.2005 allegedly due to cirrhosis of liver. The policy lapsedafter payment of annual premium due in 10/2003 and it was revived on 3.5.2005 on thebasis of a declaration of good health (DGH). As per the complainant, death was due toa sudden heart attack. The insurer enquired into the bona fides of the claim andsubmitted evidence to show that the life assured was treated as an in-patient in NIMS,Hyderabad much before revival of the policy. As per evidence produced by the insurer,the DLA was treated in the hospital (NIMS) from 29.10.2004 to 26.11.2004. As perleave record obtained from the employer of the DLA, the life assured was on longmedical leave prior to revival of the policy. The insurer contended that revival wassecured without disclosure of hospitalization. They further contended that they hadalready paid a survival benefit amount of Rs.12000 to the life assured during hislifetime and offered a paid up value of Rs.7680.00 while rejecting the claim for full sumassured. In view of the convincing evidence produced by the insurer, the contention ofthe insurer was upheld and the complaint was dismissed.Hyderabad Ombudsman CentreCase No. : L-21-001-0284-2006-07Smt. G.Satyavs.Life Insurance Corporation of IndiaAward dated 18-12-2006Head Notes: Death claim under three policies rejected on the grounds of suppressionof material facts. Insurer could prove that the LA was in a hospital taking treatment onthe date of proposal. Complaint rejected.

Facts of the Case: (Late) G.Appa Rao, son of G.Tata Reddy, Occ: Vizag Steel Plantemployee obtained policy nos. 692633510; 692633756 and 692638043 for Rs.30,000;50,000 and 60,000 respectively from Gajuwaka branch of Visakhapatnam Division ofLIC. The policies commenced on 28.3.2003; 28.3.2003 and 11.2.2004 under 14-17; 75-20 and 88-18 plans respectively. The LA died on 9.9.2004 allegedly due to heartattack. The enquiries of the insurer had revealed that the LA suffered from tremorsprior to taking of the policies. They obtained Medical book issued by the Steel PlantHospital, as per which the LA was treated in the hospital on 18.3.2003, which was thedate of proposal in respect of policy no.692633510. Proposals for the other two policieswere given subsequent to 18.3.2003. As per the medical book; the LA was known tohave suffered from lacerated wound in 4th toe (Rt.), calculitis, tremors etc and wasalso known to be a chronic alcoholic since November, 2001. Since the LA did notmention all these facts in his proposals for insurance, LIC rejected the claim on thegrounds of suppression of material information. Section 45 of the Insurance Act, 1938is not applicable. As the insurer produced necessary evidence to show that repudiationwas done on valid grounds and for valid reasons, the complaint was dismissed.Hyderabad Ombudsman CentreCase No. : L-21-001-0290-2006-07Smt. N. Baby KumariVsLife Insurance Corporation of IndiaAward Dated : 18.12.2006Head Notes: LIC repudiated death claim under a policy on the grounds of suppressionof material facts. Insurer produced medical records to show that material facts were notdisclosed at the proposal stage. Complaint was rejected.Facts of the case: (Late) N.Venugopala Swamy son of N.Dakshina Murty, Occ:Salesman in the Vizag Steel Plant Employees’ Co-op. Society obtained policyno.692744247 for Rs.1,00,000 sum assured under New Bima Kiran plan (150-22),under SSS. The policy commenced on 11.7.2005 and the LA died on 31.8.2005. Thecomplainant is the widow of the LA and the nominee under the policy. Her contentionwas that the LA died suddenly on 31.8.2005, in his sleep and that he was in goodhealth condition at the time of proposal. As per the enquiries of LIC, the LA sufferedfrom Disc Prolapse sciatica and nervous disability before issue of the policy and the LAwas on medical leave for 19 days while undergoing treatment. Since the policy wasobtained without disclosing about the medical leave and the treatment, LIC rejected theclaim. The contentions of the insurer were well supported by relevant medicalcertificates and Section 45 of the Insurance Act, 1938 is not applicable. As it wasproved by the insurer that the LA did not disclose correct information to questionsno.11 (a) to (h), the complaint was not allowed.Decision : Complaint rejected without awarding any relief.Hyderabad Ombudsman CentreCase No. : L-21-001-0267-2006-07Smt. Ratna BaiVsLife Insurance Corporation of IndiaAward Dated : 27.12.2006

Head Notes: Repudiation of death claim on grounds of suppression material facts.Insurer submitted recorded evidence to show that material information was suppressedat the proposal stage. Complaint was rejected.Facts of the case and Decision : The complainant is the wife of the LA under pol.No. 623964080. (Late) R. Umapathi obtained a policy for Rs.30,000 sum assuredbearing pol. no. 623964080 with a commencement date of 28.7.2003. He was employedas a Head Master in the Government Model Higher primary Boys School, Thyavanige atthe time of issue of the policy and he died on 1.5.2004. As per the contention of thecomplainant, the LA was healthy at the time of issue of the policy and he suffered fromdiabetes after issue of the policy in 07/2003. The insurer contended that the LA wastreated in Bapuji Hospital at Davanagere as an in-patient for 12 days from 11.1.2002.At the time of treatment he was diagnosed to be suffering from NIDDM with alcoholiccirrhosis of liver. The LA was admitted into the same hospital for treatment during histerminal illness in 04/2004 and he died while undergoing treatment due to cirrhosis ofliver. There was clear nexus between the final cause of death and the treatment takenprior to the issue of the policy. Section 45 of the Insurance Act, 1938 is applicable andthe insurer submitted enough recorded evidence to show that the LA was not healthy atthe time of proposal. As LIC could prove that material information was suppressed witha fraudulent intent, the complaint was rejected.Hyderabad Ombudsman CentreCase No. : L-21-001-0294-2006-07Smt. P.VishalammaVsLife Insurance Corporation of IndiaAward Dated : 28.12.2006Head Notes: Repudiation of death claim on the grounds of suppression of non-paymentof premium within the days of grace. Complaint rejected as the complainant could notestablish payment of premium.Facts of the case and decision :(Late) P. Siva Kumar obtained a policy bearing no.621369242 for Rs.100, 000 sumassured under Bima Kiran Plan of LIC (T&T-111-20) and nominated his mother underSec.39 of the Insurance Act, 1938. The policy commenced on 28.6.1999 and the lifeassured died on 5.2.2006. At the time of death, the first unpaid premium was due on28.12.2005. As per policy conditions, a grace period of one month but not less thanthirty days is allowed for payment of premium. If death occurs within the grace period,the sum assured is payable after deducting the premiums due within the policyanniversary. There is no dispute between the parties regarding non-payment of thepremium due in 12/2005. The complainant contended that her son could not pay thepremium due to domestic problems and also due to non-receipt of premium notice. Theinsurer offered refund of premiums amounting to Rs.8190.00 as per their rules, whichwas rejected by the claimant. The policy conditions are very clear about consequencesof non-payment of premiums. The complaint was not allowed.Hyderabad Ombudsman CentreCase No. : L-21-002-0240-2006-07Smt. K. PadmavathiVsSBI Life Insurance Co. Ltd.Award Dated : 28.12.2006

Head Notes: Life assured availed a housing loan from SBI and covered under a GroupPolicy. Claim rejected by the insurer as the LA committed suicide within one year.Complaint allowed partially on ex gratia basis.Facts of the case and decision : (Late) K.V.Basaveswar Rao, R/o Pidiguralla Townobtained a housing loan from SBI and joined the Group Insurance Scheme namely‘Super Suraksha’. The scheme is meant for borrowers from SBI and its associatedbanks. The LA was sanctioned a loan of Rs.5 lakhs and was disbursed Rs.150000 as atthe time of his death on 12.4.2006. He joined the scheme on 12.12.2005 and as per theterms of the Master Policy, death due to suicide within one year from the date ofenrollment is not covered for payment of death claim. The life assured died due todrowning in the river Krishna. As per Police Inquest and Post Mortem reports, the lifeassured jumped into the river in a mentally depressed state. The LA’s brother gave astatement to the Police, mentioning that his brother committed suicide. Death due tosuicide within one year from the date of joining the scheme is excluded from coverageas per policy conditions. However, as the insurance company collected a singlepremium for the full term of the policy for the full value of loan and as the loandisbursed was only Rs.150000, the insurer was asked to refund Rs.10000 on ex gratiabasis.Hyderabad Ombudsman CentreCase No. : L-21-001-0228-2006-07Smt. ParvathammaVsLife Insurance Corporation of IndiaAward Dated : 29.12.2006Head notes: LA committed suicide within one year from the date of vesting under aCDA plan. Complaint allowed partially and ex-gratia to the tune of premium refundallowed.Facts of the case and decision: The complainant obtained a policy no. 720708886 forRs.12000 sum assured on the life of her minor son Sri Arkesha. The policy was takenunder a CDA plan (Table-50-14) with a deferment period of seven years. The policycommenced on 28.9.1997 and the LA was 11 years old at the time of issue of thepolicy. The vesting date was 28.9.2004 and the life assured committed suicide on10.3.2005. As per policy conditions, death due to suicide within one year from thevesting date is not covered for payment of any benefit under the policy. However, asper clause 3 of the special provisions under the policy, in case of death before thevesting date, refund of premiums can be allowed. Further, the policy provides forpayment of full sum assured in the event of the LA dying after one year from thevesting date. No logic was found in the suicide clause and hence the insurer wasordered to refund the premiums collected on ex gratia basis.Hyderabad Ombudsman CentreCase No. : L-21-001-0309-2006-07Smt. AswathammaVsLife Insurance Corporation of IndiaAward Dated : 29.12.2006Head Notes: Payment of death claim under three policies rejected by LIC on thegrounds of delayed intimation of death and suppression of material facts. Complaintdismissed.

Facts of the case and decision : (Late) G.N.Satyanarayana obtained three policiesbearing nos. 611395848; 611395892; 61278821 from Pavagada and Tumkur branchesof LIC. The sum assured under the policies are Rs.25000; 50000 and 22000respectively. The policies commenced on 15.12.1999; 28.2.2000 and 28.3.2000respectively. The life assured died on 18.8.2000 and the complainant claimed moneysfrom LIC on 12.5.2005. LIC repudiated the claim under the policies stating that theclaims were barred by limitation and that the policies were obtained by suppressingmaterial information about the state of health of the life assured at the time ofproposals. The insurer contended that due to delayed intimation, they were denied anopportunity of getting full information about the cause of death of the LA and otherdetails. The insurer contended that as per their enquiries, the LA died due to suicideand he suffered psychiatric problems for about five years before death. Theycontended that the LA was treated by Dr. M.T. Satyanarayana, Head, PsychiatryDepartment, Siddartha Medical College, Vijayawada during the years 1994 to 1999. Allpolicies were taken in quick succession to secured monetary gain and reference aboutprevious policies was not furnished in the proposals given. During the personal hearingsession, the complainant admitted that her husband was treated by the doctor whomthe insurer was referring to. As the circumstantial evidence pointed towardssuppression of material information, the complaint was dismissed.Hyderabad Ombudsman CentreCase No. : L-21-001-0256-2006-07Sri K. RaviVsLife Insurance Corporation of IndiaAward Dated : 29.12.2006Head notes: Repudiation of death claim. Complainant gave a disclaimer initiallyagreeing to withdraw his claim. Subsequently he changed his stand and claimed thathe signed only on blank affidavit. Complaint allowed partially to the tune of refund ofpremium on ex-gratia basis.Facts of the case and Decision : The complainant is the brother of the DLA and theNominee under the disputed policy. (Late) K.Venkateswar Rao R/o Bandipalemobtained a policy bearing no.673091348 for Rs.1,00,000 sum assured from Jaggiahpetbranch of LIC. The policy commenced on 23.1.2004, under 14-16 Plan and with anannual premium of Rs.6344/-. The LA died on 14.4.2004 allegedly due to sunstroke asper the complainant. This policy was obtained while reviving a previous policy no.671774318 for Rs.50000 sum assured on 23.1.2004. As the previous policy had run fora longer duration and as the nominee under previous policy was the LA’s mother, LICsettled claim under the Rs.50000 policy and they repudiated claim under the latestpolicy. As per enquiries of LIC, the LA died due to AIDS, but they could not secure anydocumented evidence to that effect. As a part of their enquiry they obtained adisclaimer from the complainant, which was sworn before a Notary Public, in which thecomplainant declared that the disputed policy was obtained by his deceased brother onthe basis of fraudulent information given in proposal.The complainant contended that his brother died suddenly due to sunstroke and notdue to AIDS as alleged by the insurer. He further claimed that he signed the sworndeclaration thinking that it was a routine paper for settlement of the claim. Thecomplainant pleaded that he does not understand English, the language in which thenotarized statement was prepared and that he was misled by the Agent of LIC. All thecorrespondence with this office regarding the complaint was made by the complainant

in English, which suggest that he is taking the guidance of some knowledgeable personwhile dealing with the claim. Hence the contention of the complainant was notaccepted. However, considering the other pleadings of the complainant regardingfinancial background, it has been decided to order an ex-gratia payment in the form ofrefund of the first premium.Hyderabad Ombudsman CentreCase No. : L-21-009-0241-2006-07Smt. Veena paiVsBajaj Allianz Life Insurance Co. Ltd.Award Dated : 03.01.2007Facts of the case and Decision: (Late) Sri Viswanath Pai obtained a policy bearingno.0012235357 for Rs.1 lakh sum assured from Bajaj Allianz Life Inusrance Co. undertheir ‘Unit Gain Main Cover’ plan with the commencement date of 27.10.2005. The lifeassured died on 9.11.2005 i.e. within 11 days from the commencement date due tocarcinoma of lungs, while undergoing treatment in KMC Hospital, Mangalore. As perthe running case sheet obtained by the insurer, the LA died primarily due tobroncheogenic carcinoma and the duration of illness was recorded as five months. Asper case sheet, the LA was suffering from breathlessness for 5 months and cough withexpectoration for five months before death. The LA was also diagnosed to be sufferingfrom diabetes a month before his hospitalization for terminal illness and he was on tab.Glimiperide. The LA also was known to have a personal history of TB, HT, bronchialasthma and ischemic heart disease as per KMC Hospital record. During investigations,the insurer found out that the LA’s father suffered from cancer of colon and the LA’sbrother died of leukemia. As the LA did not disclose his personal history of persistentcough for five months and family history of cancer etc. the claim was repudiated by theinsurer through their letter dated 6.6.2006. Section 45 of the Insurance Act, 1938 is notapplicable.A personal hearing session was held on 22.12.2006 at Bangalore in which both sidesparticipated. The insurer submitted relevant hospital records. The complainantcontended that her husband did not know that he was suffering from symptoms ofcancer when he made the proposal on 25.10.2005. She claimed that the corporateagent of the insurer knew her husband very well and certified that he was in goodhealth at the time of proposal. She contended that her husband came to know of hisdisease on 6.11.2005 and pleaded for admission of the claim. She referred the orderdated 3.10.2006 of NCDRC in Revision Petition no.1696 of 2005 in the case of PraveenDamani Vs. oriental Insurance Co. Ltd. Wherein it was held that the claim was valid ifthe insured was unaware of the pre-existing disease.After examining the evidence placed on record, the contention of the insurer wasaccepted and the repudiation action was upheld. However, as the premium paid by theLA contained some investment portion, the insurer was directed to refund theaccumulated value of the savings portion of the premium.Hyderabad Ombudsman CentreCase No.L-21-002-0275-2006-07Sri M. RajeshVsSBI Life Insurance Co. Ltd.Award Dated : 31.01.2007

Head Notes: Life Assured obtained a housing loan from SBI and joined a groupinsurance policy. The LA was murdered and the insurer rejected the claim on the pleathat the Nominee under the policy was involved in the murder of his mother and hencehad no insurable interest. After a personal hearing the insurer was asked to wait forthe final outcome of the criminal case from a competent court of law.Facts of the case and Decision : (Late) Smt. M.Vajaya Lakshmi borrowed a housingloan of Rs.6 lakh from SBI, Yellareddyguda branch, Hyderabad and joined the ‘SuperSuraksha’ Master policy meant for the borrowers of housing loans from SBI and itsassociated banks. The LA submitted a proposal- cum- Good Health Declaration formdated 29.8.2003 to join the policy and paid a single premium of Rs.16596.00.Shenominated her son Mr. M.Rajesh under the provisions of Section 39 of the InsuranceAct, 1938. As per records, the LA was murdered on 6.11.2005 and the prime suspectsin the murder are the LA’s son and husband. The contents of the FIR indicate that theLA was engaged in immoral traffic, which finally led to her murder by her own son andhusband.The insurer rejected the claim on the ground that the LA obtained an ex-parte divorceorder, which is suspicious. The insurer suspected moral hazard in the transaction andas the nominee was directly involved in the crime as per FIR, they rejected the claim.During the personal hearing session, the Nominee/Complainant pleaded innocenceabout the murder and stated that another woman also was murdered along with hismother on the same day and in the same premises. He contended that the police havenot completed their investigation and a charge sheet is yet to be filed.Considering the contentions made by both sides, it was felt that the repudiation actionwas taken by the insurer in a hasty manner. Hence the insurer was directed to reviewtheir decision after receiving a final judgment from a competent court of law.Hyderabad Ombudsman CentreCase No.L-21-001-0344-2006-07Smt. B.SatyavathiVsLife Insurance Corporation of IndiaAward Dated : 31.01.2007Facts of the case and Decision:(Late) Sri B.Satyam Naidu, a resident of Booripet obtained a policy bearingno.693547048 for a sum assured of Rs.30,000 from Rajam branch of LIC. The policycommenced on 28.12.2004 under ‘Janaraksha Plan’ (T No.91-20) with a yearlypremium. The LA died on 31.1.2005 due to jaundice and as the claim was a very earlyclaim occurring in just one month from the commencement of the policy, LICinvestigated into the bona fides and repudiated for reasons of non-disclosure ofmaterial facts. As per the evidence produced by LIC, the LA underwent a Barium Mealtest in MIMS (Maharaja Institute of Medical Sciences), Nellimarla on 21.2.2004 withI.P.No.627 and was diagnosed to be suffering from stomach cancer.A personal hearing into the complaint was held on 24.1.2007 at Hyderabad and bothsides attended the session. The complainant did not totally deny treatment taken fromMIMS, Nellimarla, but she contended that her deceased husband took treatment forstomach pain. She further stated in one of her letters addressed to LIC that herhusband took herbal medicines for treatment of jaundice just one week before deathand was cured of the disease. Considering the duration of the policy, nature of diseasesuffered by the LA during his terminal illness, information given by the complainant to

LIC about usage of herbal medicines, it became evident that the LA was not in goodhealth at the time of making the proposal. Hence, the decision of the insurer wasconsidered to be justified. However, considering the appeal of the complainant that shehails from a very poor family, it was decided to order an ex-gratia payment ofRs.10,000 to the complainant.In essence, the complaint was allowed partially.Hyderabad Ombudsman CentreCase No.L-21-001-0331-2006-07Sri G. MattiahVsLife Insurance Corporation of IndiaAward Dated : 31.01.2007Facts of the Case and Decision:(Late) Smt. G. Anjamma obtained a policy bearing no.670020130 for Rs.50,000 sumassured from Narasaraopet branch of LIC, with the commencement date of 20.4.2005.The LA nominated her brother Sri G.Mattiah as the beneficiary under Sec.39 of theInsurance Act, 1938. The LA was engaged in handloom weaving and was aged 36years at the time of proposal. The LA died on 2.10.2005 and claim occurred in about 5month’s time. As per claim papers submitted to LIC, the LA died due to spinal cordinjury. The claim was rejected by LIC through their letter dated 7.12.2005.A personal hearing session was held on 20.12.2006 at Hyderabad in which both sideswere represented. The insurer contended that the LA was not healthy at the time ofproposal in 05/2005 and she suffered a bone fracture in 03/2005. As per the insurer,the LA was admitted into Susmita Ortho & Trauma Care Hospital, Narasaraopet on12.4.2005 with a history of weakness of all four limbs since one month. She wasdischarged from that hospital on 21.4.2005 in a very bad condition. The insurerproduced a certificate in their form B-1 in which the last medical attendant certified thatthe LA was suffering from Quadriparesis due to cervical cord compression and thedoctor did not mention about injury anywhere in his statement.The complainant/Nominee contended that the LA suffered spinal cord injury after anaccidental fall on 10.7.2005, which finally led to her death on 2.10.2005. He contendedthat the period of treatment was from 10.7.2005 to 20.7.2005 for the injury and notbefore commencement of the policy.Section 45 of the Insurance Act, 1938 is not applicable as the claim was rejected withina period of 2 years from the date of risk on grounds of suppression of material factsrelating to the health condition of the LA.After examining the evidence placed on record, it was decided to uphold therepudiation action taken by LIC. The case was dismissed without any relief.Hyderabad Ombudsman CentreCase No.L-21-009-0315-2006-07Smt. Ch. DurgammaVsBajaj Life insurance Co. Ltd.Award Dated : 31.01.2007Facts of the case and Decision:(Late) Chakka Pitchiah obtained a policy bearing no.0008524952 for a sum assured ofRs.2,50,000 from the insurer under ‘Unit Gain’ plan. The policy commenced on

20.4.2005 and the LA was engaged in hotel business. He was 54 years old and thepolicy was taken or a 25 year term. The LA died on 25.2.2006 and cause of deathreported to the insurer was for natural reasons. The complainant is the nominee underthe policy and she raised the present complaint before this office after refusal of herclaim by the insurer through their letter dated 19.7.2006. Section 45 of the InsuranceAct, 1938 is not applicable. A personal hearing session was held on 24.1.2007 atHyderabad and both sides attended the session.The LA died in about 10 months time and the policy was issued under non-medicalscheme. As per evidence secured by the insurer, the LA had undergone ECG test on14.1.2002 and he was shown to be of 70 years old at that time. The insurer produced acopy of Health Card from SSH Dispensary dated 7.2.2001, wherein the LA was shownas 75 years old and was stated to have been treated from 14.2.2005 to 20.2.2005.The complainant contended that her husband visited a doctor on 14.11.2002 becauseof body pains. He had undergone ECG as suggested by the doctor and no problem wasnoticed in the ECG. In the month of 04/2005, the LA consulted a Homeo doctor forknee pains, which was a minor problem. She contended that there was nounderstatement of age of the LA and there was no history of treatment for any disease.After personal hearing session and after examining various papers submitted by bothsides, it was felt that the insurer has not proved in a convincing manner aboutsuppression of material information. As the insurer could not produce any substantialevidence to prove their point, the complaint was admitted and the insurer was asked topay benefits under the policy.Hyderabad Ombudsman CentreCase No.L-21-001-0380-2006-07Smt. M.RavanammaVsLife Insurance Corporation of IndiaAward Dated : 31.01.2007Facts of the Case and Decision:(Late) M. Malli Babu S/o Bapanna obtained a policy no.693403757 for a sum assuredof Rs.1 lakh from Rajam branch of LIC. The policy was taken under ‘jeevan Anand’ plan(T-149-16) with a half yearly premium of Rs.4285.00 and the commencement date was26.3.2004. The LA died on 22.5.2005 due to renal failure. As death claim occurredwithin a period of one year, LIC enquired into the bonafides of the claim and repudiatedthe claim vide their letter dated 31.3.2006. The claim was rejected stating that the LAunderstated his age at the time of proposal and did not disclose information aboutprevious insurance policies while proposing for the present policy.A personal hearing session was held on 24.1.2007 at Hyderabad and both sides werepresent and submitted their contentions. The insurer contended that during the courseof their investigations, they came to know that the LA had a previous policy bearingno.690342135 for Rs.60,000 and it matured on 28.3.2005. As per the old policy, the LAwas born on 1.12.1943, while the DOB declared under the present policy was 1.7.57.They contended that there was a clear understatement in age by 14 years and allegedthat the LA made a deliberate understatement to commit a fraud on them.The complainant contended that she was not aware of the previous policy as thematurity value was claimed by the LA during his life time. She claimed that herhusband was given the present policy based on a voter identity card, which is a valid

age proof. She requested for settlement of the claim pleading that her husband was notwell educated to know the intricacies of various kinds of age proofs.After the personal hearing session and after examination of various papers, it becameevident that there was an understatement of age by 14 years. The LA was found to beat fault for not disclosing correct information at the time of proposal. However,considering the fact that the proposal was accepted under medical scheme, it wasdecided to award an ex- gratia relief in the form of refund of amount paid as premiums.In effect, the claim was allowed partially.Hyderabad Ombudsman CentreCase No.L-21-001-0335-2006-07Smt.K.SatyavathiVsLife Insurance Corporation of IndiaAward Dated : 31.01.2007Facts of the Case and Decision:The complainant is the nominee under the disputed policy no. 693039454 and is thewidow of the DLA. Her husband, late K.Narsinga Rao obtained the policy fromNarsipatnam branch of LIC for a sum assured of Rs.1 lakh. The policy commenced on7.6.2003 (T-149-21) and the LA died on 30.6.2005. The claim was rejected by LIC videtheir letter dated 31.3.2006, stating that the LA did not disclose his actual condition ofhealth when the policy was revived on 2.3.2005.A personal hearing session was held on 24.1.2007, in which the complainant was notrepresented.As per facts of the case, the policy lapsed after payment of the monthly premium of01/2004 and it was revived on 2.3.2005 by paying 13 months premiums, which were inarrears. The revival was done on the basis of a ‘State of Good Health’ and claimoccurred in about four months time after revival. LIC obtained a Certificate in claimform no.5152 issued by the Civil Asst. Surgeon of Government TB & FP Clinic,Narsipatnam, as per whom the LA was treated as an out-patient since 2.8.2004 withhistory of cough, fever, breathlessness and HIV. The insurer contended that they wouldnot have revived the policy in the event of disclosure about past treatment.The complainant contended that her claim is genuine and LIC rejected her claim onsome statements made by their neighbours out of envy and jealousy.Considering the evidences placed on record, it was decided to uphold the decisiontaken by LIC and the complaint was dismissed without any relief.Hyderabad Ombudsman CentreCase No.L-21-006-0333-2006-07Smt.Tarani MeenaVsBirla Sunlife Insurance Co. Ltd.Award Dated : 08.02.2007Facts of the Case and Decision:(Late) Sri Venugopal Ramaswamy obtained two policies bearing nos. 000075954 and000460316 from the insurer in 03/2003 and 9/2005 respectively. Policy No. 75954 was

taken under ‘Flexi Cash flow’ plan for a sum assured of Rs.1,50,000 with thecommencement date of 12.3.2003. The second policy no.460316 was taken under‘Classic Life’ plan for a sum assured of Rs.5 lakhs and it commenced on 8.9.2005.Policy no.75954 covered three types of riders namely (i) Accidental death &dismemberment rider (ii) Critical illness rider (iii) Term rider. These riders are inaddition to the basic life coverage.The LA died on 24.1.2006 due to cardio pulmonary arrest, after a prolonged illness.The insurer settled claim for basic sum assured under policy no. 75954 and rejectedCritical Illness benefit. They also rejected total claim under the second policy, allegingthat the LA did not disclose material information about his state of health whileproposing for the policy. The C.I. benefit under Pol. No.75954 was rejected stating thatthe LA did not suffer from ‘Stroke’, coming within the meaning of the term defined inthe policy conditions.A personal hearing session was held on 13.12.2006, in which both sides participated.The insurer contended that C.I. benefit under the first policy could not be paid, as theLA did not suffer any paralytic stroke. The LA had his first spell of hospitalization forhis terminal illness on 16.9.2005.With regard to the other policy, the LA submitted his proposal on 28.6.2005. As thecase sheet of hospital revealed that the LA was having a history of chronic alcoholism,the insurer rejected the claim stating that the LA did not disclose his personal historyof alcoholism. This point was refuted by the complainant, stating that her husband haddisclosed about his habit of taking drinks. She also contended that the second policywas issued after a medical examination by a doctor designated by the insurer.After a careful examination of the evidences placed on record, it was decided to orderfor payment of claim under the second policy for Rs.5 lakh sum assured. It was alsodecided to uphold the decision of the insurer regarding payment of C.I. benefit underthe first policy.Hyderabad Ombudsman CentreCase No.L-21-001-0423-2006-07Smt.RatnasreeVsLife Insurance Corporation of IndiaAward Dated : 22.02.2007Facts of the case and Decision:(Late) N. Srinivas obtained a policy bearing no.663085363 for Rs.50,000 from Raichurbranch of LIC. The policy commenced on 26.2.2003 under plan 91 for 21 years. The LAdied in a road accident on 22.7.2004. As per police records and Post Mortem report,the LA was under the influence of alcohol at the time of accident.Based on the claim papers received, the insurer settled the claim for basic sumassured of Rs.50000 and rejected double accident benefit stating that the benefit is notpayable as per exclusion clause provided under Cl. 10(b)(i). The present complaint isagainst the decision of LIC not to pay accident benefit amount. The insurer quoted thejudgment given by NCDRC, Delhi under FA No.368/2004 as a case law, whereunder itwas held by the Hon’ble Forum that the construction of the particular word“intoxication” and its meaning are to be read within the terms and conditions of thepolicy.The complainant, who is the Nominee under the policy, contended that her husbandwas not drunk at the time of accident and that the Police filed the FIR at the behest of

the owner of the opposite vehicle involved in the accident. The LA was riding amotorcycle at the time of accident and the opposite vehicle involved was a heavyvehicle.After hearing the contentions of both sides it was decided to uphold the decision takenby LIC, as the exclusion clause provided in the policy is very clear about non-paymentof the benefit when the LA is under intoxication. In effect the complaint is dismissed.Hyderabad Ombudsman CentreCase No.L-21-001-0419-2006-07Smt. K.V.LalithammaVsLife Insurance Corporation of IndiaAward Dated : 22.02.2007Facts of the Case:(Late) K. Ramappa s/o Thimmaji obtained policy no.660998180 for a sum assured ofRs.1,00,000 from Hospet branch of LIC. The LA nominated his wife Smt.K.V.Lalithamma under Sec.39 of the Insurance Act, 1938. The policy commenced on5.6.2003, under T-149-16 with a half-yearly premium of Rs.4785.00. The LA died on7.11.2004 and his age at entry was 57 years. The policy was completed under Medicalscheme of LIC. The policy completed duration of 1Y-5M at the time of death.As the claim turned out to be a very early one as per standards of LIC, theyinvestigated it repudiated on 27.3.2006 on the grounds that the LA did not discloseabout his voluntary retirement from service on health grounds. The LA was employedwith Indian Railways and he took VRS w.e.f.28.2.2003.As per evidence obtained by LIC, the LA was treated as an in-patient in the RailwayHospital for hypertension since 25.5.2001. He was on regular treatment thereafter andhe was treated in the hospital from 29.6.202 to 27.11.2002. The doctors of Railwayhospital have recommended for VRS on health grounds and the LA applied for VRS on19.11.2002. He was discharged from service on 28.2.2003. The LA however did notdisclose the details of previous treatment and reasons for his voluntary retirement fromservice in his proposal dated 4.6.2003. The insurer produced a photo copy of themedical pass book issued by the Railway Hospital to support their action of repudiationof claim.DECISIONThe LA was aged 57 when he applied for insurance and his proposal was completed onthe strength of a medical report. The LA did mention in his proposal that he was aretired employee of Railways. This indicates that the insurer had a fair chance ofknowing further about the retirement status and about actual condition of health.Hence, there appears to be some failure on the part of the insurer in getting requireddata before issuing the policy. Considering the other facts, it was decided to award anex-gratia payment of Rs.50,000.Hyderabad Ombudsman CentreCase No.L-21-001-0332-2006-07Smt. Vanitha Laxman RaghunathiVsLife Insurance Corporation of IndiaAward Dated : 22.02.2007

Head Notes: Life assured had two policies on his life and died within a short periodfrom the commencement dates of the policies. LIC repudiated the claims on the pleathat the LA did not disclose his personal medical history correctly. Evidence submittedby LIC was found to be in order and hence the complaint was dismissed.Facts of the case:(Late) Laxman Venkatesh Raghunathi, Agricultural Assistant in the office of the Asst.Director of Agriculture, Sirsi obtained policies bearing nos. 632187163 for Rs.50000and policy no.638815586 for Rs.30000 from Sirsi branch of LIC with commencementdates of 25.3.2003 and 20.3.2004 respectively. The policies were issued under Plan14-20; 14-15 respectively and under SSS scheme. The LA died on 15.11.2004. As theclaims were treated as early claims, LIC investigated the claims and repudiated thesame as they came to know that the LA was under treatment even beforecommencement of the policies. As per evidence collected by LIC, the LA was admittedinto Rotary Charitable Hospital, Sirsi on 3.10.2002 with complaints of abdominal pain,viral hepatitis and was discharged on 5.10.2002. Further, the enquiries of LIC revealedthat the LA was a chronic alcoholic and death was due to alcoholic cirrhosis. As the lifeassured did not disclose about his hospitalization in 10/2002 for viral hepatitis, LICrepudiated the claim vide letter dated 9.3.2005.Section 45 of the Insurance Act, 1938 isnot applicable.Decision : LIC settled death claims under some more policies which were held by theLA, which come under non-early category. As per the complainant, the LA sufferedfrom illness for about a month before death, while the insurer contended that the LAwas suffering from hepatitis since 3.10.2002. They have also pleaded that there is anexus between the final cause of death and the disease for which the LA washospitalized in 10/2002. As the evidence produced by LIC was found to be in order, thecomplaint was dismissed for reasons of non-disclosure of material information.Hyderabad Ombudsman CentreCase No.L-21-001-0392-2006-07Smt. Renuka BarkiVsLife Insurance Corporation of IndiaAward Dated : 26.02.2007Head Notes: Early death claim on a policy for Rs.30000 sum assured. Death occurreddue to suicide and the LA had a proven past medical history of mental illness. Claimwas rejected by LA for reasons of suppression of past medical history. Based on theevidence produced by LIC, the complaint was dismissed without any relief.FACTS OF THE CASE AND DECISION :Late Laxman Barki, the LA under policy no.637188463 submitted a proposal for thepolicy to Haveri branch of LIC on 8.8.2003. He nominated his sister Smt. Renuka underSec.39 of the Insurance Act, 1938. The LA allegedly committed suicide on 23.11.2004by falling under a running train and as per police records, it was held to be a case ofsuicide due to mental illness. As the LA died in about one year-three months periodfrom the commencement date of the policy, LIC investigated the claim. As per formssecured by LIC, the LA was treated in Manasa Nursing Home at Shimoga from14.10.1995 to 20.10.1995 for mental disorder. The cause of death also was attributedto mental disorder by the complainant in her claim forms given to LIC. The LA wastreated in the Government Mental Hospital, Dharwad from 9.4.2004 to 8.5.2004. As thefinal cause of death is due to mental disorder, the insurer could establish a clear nexusbetween the past medical history and cause of suicide. As the insurer’s repudiation

action was found to be based on proper evidence, it was decided to uphold therepudiation action and accordingly the complaint was dismissed.Hyderabad Ombudsman CentreCase No.L-21-002-0304-2006-07Smt. ChandiniVsSBI Life Insurance Co. Ltd.Award Dated : 28.02.2007Head Notes: Life assured was a borrower of housing loan from SBI and joined a groupinsurance policy of the insurer. Claim was repudiated on the plea that the life assuredwas suffering from a critical illness even prior to joining the policy. The evidenceproduced did not indicate any past medical history and hence the complaint wasadmitted.Facts of the case and Decision :(Late) Sri Ramesh borrowed a loan of Rs.7,50,000 from SBI, Mangalore branch forhouse construction purpose. He joined “Super Suraksha” master policy of SBI Life, bysubmitting a good health declaration form dated 23.11.2004. The group policy is meantfor housing loan borrowers of SBI and its associate banks. As per policy conditions,risk coverage is available for the outstanding loan as per original EMI scheduletogether with outstanding interest. The LA died on 10.3.2006 due to Hepato CellularCarcinoma while taking treatment in City Hospital Research & Diagnostic Centre,Mangalore. The claim was repudiated by the insurer stating that the LA was sufferingfrom liver disease prior to the date of joining the scheme. A personal hearing into thematter was held on 14.2.2007.The insurer produced copies of prescriptions dated 24.11.2004 and a certificate from adoctor named Dr. B.V.Tantry in which it was stated that the LA was suffering fromjaundice and other ailments for about one and half months before. The complainantcontended that her husband was healthy at the time of proposal for insurance. The LAwas working as a Junior Traffic Assistant in New Mangalore Port Trust, Panambur. Shecontended that her husband first consulted a doctor on 8.1.2006. She also contendedthat the investigator appointed by SBI Life misbehaved with her when he came forinvestigating the claim. She claimed that the investigator demanded some money for afavorable report and on her refusal to pay money; the investigator submitted fabricatedmedical report dated 24.11.2004 from Dr. B.V.Tantry and the insurer repudiated herclaim on the basis of that report. She claimed that the investigator of the insurerfabricated some certificates purported to have been issued by Dr. B.V.Tantry to takerevenge against her for her refusal to pay money. It was also held by her that shelodged a police case against the investigator for his alleged misbehavior with her. Itwas her claim that her husband was not treated in the hospital in the year 2004 asmade out by the insurer.After personal hearing session and after examining all the papers produced by theinsurer, it was decided to reject the contention of the insurer. The insurer was orderedto admit the claim as per policy conditions.Hyderabad Ombudsman CentreCase No.L-21-009-0438-2006-07Sri V.Surya NarayaVsBajaj Allianz Life Insurance Co. Ltd.

Award Dated : 28.02.2007Head Notes: Death claim under a unit Linked policy. Evidence produced by the insurerproved that the LA was under treatment for hypertension prior to the issue of thepolicy. Complaint was allowed on ex gratia basis to an extent of refund of theinvestment portionFacts of the case and Decision :(Late) Varasala Bhimayya, aged 56 years at the time of proposal, obtained policyno.1854778 for a sum assured of Rs.75,000 from the insurer under a Unit Regularpolicy. The policy was issued under a non-medical plan and it commenced on19.10.2005 with an annual premium of Rs.15,000. The LA died on 11.7.2006 i.e. within9 months from the commencement of the policy and the insurer rejected the claim videtheir letter dated 22.11.2006 on the plea that the LA was suffering from hypertensionfor three years before the issue of the policy.Before death, the LA fell from a staircase on 28.6.2006 and fractured his left hip. Hewas advised complete bed rest and on 11.7.2006 he died of heart attack. The LA wastreated by Dr. R.Ramakrishnam Raju during the terminal illness and he was the familyphysician of the LA. The doctor knew the LA for about ten years and as per the doctor,the LA was suffering from hypertension for about three years and was prescribed Aten-50. He was under the treatment of Dr. Krishnam Raju as an outpatient. The insureralso obtained a questionnaire completed by a family member of the LA, who haddeclared that the LA was using medicines for hypertension for about one year. As theinsurer has established suppression of material information, the complaint was found tobe not entertained. However, as the policy has a provision for savings, the insurer wasordered to refund such investment portion on ex gratia basis.Hyderabad Ombudsman CentreCase No.L-21-002-0354-2006-07Sri B.S.SivaramakrishnaVsSBI Life Insurance Co. Ltd.Award Dated : 12.03.2007Head Notes: Life assured obtained a housing loan from State bank of Mysore andbecame a member of group ‘Super Suraksha Plan’ of SBI Life for coverage ofoutstanding loan. Death claim repudiated on the plea that the LA was suffering fromcritical illness prior to joining the scheme. Insurer could not prove convincingly aboutexistence of disease prior to membership. Hence complaint was admitted.Facts of the case and Decision :(Late) S.B.Beleri, aged 53 years, occupation- Security Guard in State Bank of Mysore,Bhadravathi, became a member of the group ‘Super Suraksha Plan’ of SBI effectivefrom 5.11.2003. The LA submitted an application cum Good Health Declaration of evendate to join the plan. The group policy is meant for borrowers of housing loan from SBIand its associate banks. The LA secured a housing loan from SBI, Shimoga branch andto get insurance coverage on the outstanding loan, he became a member of the supersuraksha plan.The LA died on 15.9.2005 due to HIV. The death claim payment was rejected by theinsurer on the plea that the LA was a HIV patient even before becoming a member ofthe scheme.A personal hearing was held at Bangalore on 14.2.2007. The insurer contended thatthe insurer was infected with HIV about two years before his death and produced a

certificate issued by one Dr.H.R.Devendrappa. As per the doctor’s report, the LA wasadmitted into the hospital on 5.9.2005 with complaints of diarrhea, cough for threemonths. In the hospital, the LA was diagnosed to be suffering from HIV. It wasrecorded in the case sheet that the LA was first observed to be suffering from thedisease about two years before. The insurance company took back the origin of thedisease to 09/2003 in a very arithmetical manner and came to the conclusion that theLA was affected with the disease even before joining the scheme.The complainant contended that his father was not having any knowledge of thedisease till 09/2005 and he was regular in going to his office till 08/2005. Owing togeneral weakness and frequent fever his father went to Nanjappa Hospital fortreatment. In that hospital only, his father was tested positive for HIV.After hearing both sides and after examining the evidence placed on record it becameevident that the insurer rejected the claim without obtaining adequate evidence toprove that the LA was tested positive for HIV before 5.11.2003. As the insurer did anarithmetical calculation of deducting 2 years from the doctor’s report to arrive at theonset of the disease, the insurer’s contention was not accepted. The complaint wasadmitted and the insurer was asked to settle the claim.Hyderabad Ombudsman CentreCase No.L-21-001-0463-2006-07Smt. U.Sudha RaniVsLife Insurance Corporation of IndiaAward Dated : 14.03.2007Head Notes: Death claim under two policies rejected by LIC on the plea that the LA didnot disclose about existence of previous policies. The complaint was dismissed as itwas found that the LA failed to disclose previous insurance particulars.Facts of the Case and Decision: (late) U. Ramesh obtained two policies bearingnos. 6723083305 for Rs.2,00,000 and 672368239 for Rs.1,00,000 in 02/2001 & 06/2002respectively. The L A died on 27.9.2004 and the claim was repudiated on 29.4.2005.Section 45 of the Insurance Act, 1938 is applicable. As the claim under the two policieswas treated as ‘early’ one, LIC enquired into the merits of the matter. As per enquiriesof LIC, the LA had another policy bearing no.672356954 for Rs.2 lakh taken under Plan113-30 for which a proposal was submitted on 14.2.2001.Thus the LA had threepolicies in all on his life at the time of death. The proposal for pol. no.672308335 wasgiven on 15.2.2001 and proposal for the third policy no.672368239 was given on28.6.2002. As per LIC, the LA did not mention about existence of the first policy whilegiving proposal for the second policy. So also the LA did not disclose details of the firstand second policies in the proposal for third policy. LIC settled claim under the firstpolicy no.672356954 for Rs.2 lakhs as it was the first policy and treated omission ofdetails of earlier policies in the remaining policies as a deliberate act on the part of LAto commit a fraud on them. All the three policies were taken under medical scheme ofLIC. LIC contended that the LA submitted the proposals in different branches to avoidscrutiny. The contention of LIC was accepted and the complaint was dismissed.Hyderabad Ombudsman CentreCase No.L-21-009-0464-2006-07Smt. K.SwaroopaVsBajaj Allianz Life Ins. Co. Ltd.

Award Dated : 21.03.2007Facts of the case and Decision:The complainant is the nominee under the policy no. 11552753 for a sum assured ofRs.5 lakhs taken by (late) Kandukuri Dayakar. The policy was ‘Unit Gain’ plan and theLA paid first installment premium of Rs.10,000. Term of the policy was 31 years. TheLA died on 9.12.2005 allegedly due to white jaundice. The claim was rejected by theinsurer vide a letter dated 3.8.2006 alleging that the insured had grossly overstated hisincome in the proposal dated 30.9.2005.The insurer also held in their rejection letterthat the claimant submitted an invalid death certificate containing discrepancies. Apersonal hearing session was held on 27.2.2007 at Hyderabad in which both sideswere represented.The insurer contended that the LA declared an annual income of Rs.150000 in theproposal, while their enquiries revealed that the LA’s income was only Rs. 30000 asper ration card for the year 1998-2003. The insurer also claimed that the widow of theLA was mentioned as the head of the family in the ration card. The insurer furtherclaimed that the complainant could not produce a fresh ration card for the current yearand hence they rejected the claim.The complainant produced a certificate issued by Mandal Revenue Officer (MRO) oftheir town showing an income of Rs.98,000. The complainant also declared that heowns a General Stores and Telephone booth from which they get substantial income.She informed that she declared the sources of income to the MRO to get an incomecertificate. From the insurer’s side there was no record to disprove the certificateissued by the MRO. The complainant further produced a revised death certificateshowing correct date of death. During the personal hearing session the insurer’srepresentative informed that they would have given a sum assured of Rs.5,00,000 foran annual income of about Rs.1 lakh. As the policy was issued to the DLA afterobtaining a Moral hazard Report from the Agent/Sales Team Manager, it was decidedto allow the complaint. The insurer was ordered to settle claim as per policy conditions.Hyderabad Ombudsman CentreCase No.L-21-001-0458-2006-07Smt. V. MadhaviVsLife Insurance Corporation of IndiaAward Dated : 26.03.2007Facts of the case & Decision:(Late) V. Niranjan Reddy obtained policy nos.670686205 and 671466311 from Ongolebranch of LIC. The first policy commenced on 15.3.1993 for Rs.25000 and the secondpolicy on 15.3.1997 for Rs.25000. The policies were revived on 10.12.2004 and20.8.2004 respectively on non-medical basis by submitting DGH. The LA died on31.12.2004 and the claims under both policies were rejected by LIC on grounds ofsuppression of material information at the time of revival. LIC offered to pay paid upvalue under the policies, but the complainant approached this office for admission ofclaims for the full sum assured.The cause of death was cancer of buccal mucosa of rt.cheek with secondaries in liverand brain. The insurer investigated the claim and found out that the LA was undertreatment since 15.10.2003 for ulcer in mouth. LIC collected relevant hospital recordsin support of their repudiation action. As LIC could prove beyond doubt about the LA’s

suffering from disease prior to revival of the policies, repudiation of claims was upheld.LIC’s decision to offer paid up value under the policies was held to be in order.Hyderabad Ombudsman CentreCase No.L-21-001-0445-2006-07Smt. S.RadhikaVsLife Insurance Corporation of IndiaAward Dated : 27.03.2007Facts of the case & Decision:(Late) Settipalli Harikrishna obtained policy no.840686049 for a sum assured of Rs.2lakhs from Atmakur(N) branch of LIC under T-107-T-20 with a half yearly premium ofRs.9272.00. The policy commenced on 28.1.2001 and it lapsed after payment of firstpremium. The policy was revived on 9.5.2002 under medical scheme, on the basis of aDGH dated 30.4.2002 and after collecting two installments premium. The policy againlapsed from 07/2003 due month and again it was revived on 13.9.2004 by paying 3 halfyearly installments. The second revival also was done on medical basis. The LA diedon 2.1.2005 due to suicide. As the claim occurred in a very short period from the dateof revival on 13.9.2004, LIC investigated the claim. They found out that the LA met witha road accident on 28.4.2003 and the LA’s rt. leg below knee level was amputated andthe cause of suicide was attributable to the heavy debts raised by the LA for histreatment. The DGH dated 12.9.2004 did not contain details of accident or amputation.LIC contended that they would not have revived the policy in the normal course hadthere been a disclosure by the LA about amputation of his leg. As the LA was found tosubmit a false DGH they rejected the claim.A personal hearing of both sides was held on 15.3.2007. The complainant contendedthat the agent of LIC did not pay premiums to LIC even after collecting money from herlate husband. The Agent of LIC arranged for medical examination. She contended thatthe signatures on the DGH do not tally with her deceased husband’s usual signature.After hearing the contentions of both sides and examining the papers produced, it wasdecided to allow an ex gratia relief in the form of refund of the amount paid at the timeof second revival that took place on 13.9.2004. In effect, the complaint was allowedpartially.Hyderabad Ombudsman CentreCase No.L-21-002-0446-2006-07Smt. P.DharmavathiVsSBI Life Insurance Co. Ltd.Award Dated : 28.03.2007Facts of the case and Decision:(Late) P.V.Suryanaraya became a member of ‘SBI Life Super Suraksha’, a home loaninsurance policy for the borrowers of SBI group effective from 27.9.2004.The LAborrowed a home loan from SBH, Anakapalle and joined Group policy no.83001000507.The LA availed a second housing loan from SBI Anakapalle and became member ofanother group policy no.83001000203 w.e.f 8.11.2005.The loan from SBI wasRs.4,92,000 and loan from SBH was Rs.3,50,000. The LA died on 19.2.2006 due toliver cancer. The claim under both policies was rejected by SBI Life vide their letterdated 27.9.2006, stating that the LA submitted a false DGH to join the schemes. Apersonal hearing of both sides was held on 15.3.2007 at Hyderabad.

Contentions of Insurer: Admission into the policies was based on two separate GoodHealth Declarations. As per such declarations, the LA should not be suffering from anyphysical defect or deformity at the time of joining and he should be in sound health. Asper the scheme, persons suffering from any physical defect or deformity are not eligibleto become members. As per their investigations, the LA was a physically handicappedperson with 50% disability. He got a government job under P.H. quota and as such wasnot eligible to join the schemes. Had the LA disclosed about his disability, they wouldnot have admitted into the schemes. The insurer was not medically examined beforeentry into the schemes.Contentions of the complainant: Her husband joined a Government job in the year 1986and he worked as a Teacher till his death without taking any kind of help from others.He was having only residual polio and not suffering with defect or deformity. Herhusband did not die of deformity but died due to liver cancer. Before entering thescheme, her husband discussed with the bank authorities about his deformity and thebank officials did not object to his joining the schemes. Further, her husband’sdeformity was clearly visible to viewers and his disability was not a thing that could behidden.Decision: The main reason for rejection of the claim was non-disclosure of thedisability of the life assured. The insurer produced medical leave record of the LA as apart of their defense. As per leave record, the LA was on sick leave from 13.9.2005 to22.9.2005. This leave is prior to the LA joining policy no.83001000203. Hence, theaction of the insurer was upheld. Considering the duration of the membership underPolicy no.83001000507, it was decided to order the insurer to settle claim on gratisbasis. In effect, the complaint was allowed partially.Hyderabad Ombudsman CentreCase No.L-21-001-0442-2006-07Sri V. JakeerVsLife Insurance Corporation of IndiaAward Dated : 30.03.2007Facts of the case & Decision:(Late) Smt. V.Haseena w/o Sri V. Jakeer obtained a policy bearing no.841320285 forRs.28000/- from Piler branch of LIC. The policy commenced on 28.3.2002 under newJanaraksha plan (T&T91-15). The LA paid a half yearly premium of Rs.1034-00 and shewas a cultivator as per proposal form. The LA died on 7.6.2003 allegedly due to highfever. When the complainant submitted claim papers, LIC investigated the claim as theLA died in a very short period from the commencement date of the policy. As per theinvestigation of LIC, the LA had another policy for Rs.1 lakh sum with a policyno.840507757. The details of this policy were not mentioned while securing policyno.841320285. LIC rejected claim under the policy for Rs.28000/- and settled claim forRs.1,00,000 under the first policy. The contention of LIC is that they give insurance toself-employed females up to a maximum of Rs.1 lakh and insurance beyond that will besubject to a matching policy being there on husband’s life. In the present case as theLA’s husband was not holding any matching insurance, LIC rejected the claim on thesubsequent policy.The complainant contended that his wife paid three premiums in all with her hardearned money and requested for payment of full claim.A personal hearing of the parties was held on 28.3.2007. The complainant remainedabsent for the session and he did not deny the grounds of repudiation. As LIC could

establish that the LA failed to disclose about a previous policy for a high sum assuredof Rs. 1 lakh, the repudiation action was upheld and accordingly the complaint wasdismissed without any relief.Hyderabad Ombudsman CentreCase No.L-21-009-0469-2006-07Sri I.Ramalingeswar RaoVsBajaj Allianz Life Insurance Co. Ltd.Award Dated : 30.03.2007Facts of the case & Decision:(Late) Smt. Itha Sathyavathi, a resident of Vijayawada obtained a policy bearing no.10098354 for a sum assured of Rs.150000 under ‘Unit Gain’ plan and paid a firstpremium of Rs.30,000.The policy commenced on 18.8.2005 and the LA died on22.3.2006.The complainant is the son of the LA and the nominee under the policy. TheLA died as a result of a sudden heart attack. As the LA died in about seven monthsfrom the commencement of the policy, the insurer enquired into the bonafides of theclaim. As per their enquiries, the LA was known to be a diabetic for about three yearsbefore death. This information was given in the Last Medical Attendant certificateproduced by the claimant. The complainant also admitted to the fact of treatment of hismother for diabetes. The main contention of the insurer is that the LA did not discloseabout her medical history of diabetes in her proposal form dated 03.8.2005 andpleaded that they would not have issued the policy had there been a disclosure abouttreatment for diabetes.The complainant in his submission during a personal hearing session held on28.3.2007 stated that his mother used to take oral pills for diabetes and she neverfaced any problem with diabetes. He stated that her diabetes was well under controland his mother was kept in dark by the agent about specific reply given to the relevantquestion in the proposal. He further mentioned that his mother was aged 58 years atthe time of policy issue and his mother signed on the dotted line as per the suggestionof the agent.After hearing the arguments of both sides and after examining the papers produced, itbecame evident that the insurer succeeded in proving that the LA did not discloseabout her history of diabetes. Hence it was decided to uphold the rejection action andoffer refund of the first premium paid as ex gratia relief.Hyderabad Ombudsman CentreCase No.L-21-001-0470-2006-07Smt. P.SaradammaVsLife Insurance Corporation of IndiaAward Dated : 30.03.2007Facts of the case and Decision:The complaint is about three policies taken on the life of (late) P.Nagabhushanam,Driver in APSRTC. Policy nos. 650292691; 650523409; 841852558 were taken underSSS. The policies commenced on 28.11.1190; 20.3.1995; 28.4.1998 respectively forRs.50000; 25000 & 10000.The LA was murdered on 23.6.2000 and LIC settled claimsonly for basic sum assured. Though the policies were covered for accident benefit, LICrejected payment of AB on the plea that the LA was murdered in a faction feud. As perrecord, the LA was involved in another murder case and he was on a conditional bail

on the date of his murder. The LA was to report in a particular police station every dayas a part of conditional bail and on the fateful day his enemies intercepted the bus inwhich he was travelling and murdered him. As the LA’s murder was provoked by hisinvolvement in another crime, LIC interpreted that murder in this case does not fallwithin the scope of accident defined in the policy conditions. They also cited thejudgment given by NCDRC, New Delhi in appeal no.204 of 1999 in which the Hon’bleforum clarified when a murder amounts to accident. As per the Hon’ble Forum, if thedominant intent of the perpetrator of a crime is to kill a particular person, the actmurder cannot be called as an accident.The complainant contended that her husband had no criminal record. According to her,her husband was murdered due to mistaken identity. She further pleaded that as all theaccused in her husband’s murder were let off by the Sessions Court dealing with thecase, the murder should be treated as an accident. She further stated that shereceived similar accident benefit from New India Assurance Co. Ltd. under a policyno.61020/47/00438 for Rs.1 lakh on the basis of an award passed by the OFFICE OFINSURANCE OMBUDSMAN-HYDERABAD during 2005-06 under Award No.G-94.Decision: As the complainant made a reference to an old award of this office, the factsof the matter were carefully examined. The LA was murdered on 23.6.2000 and thefinal verdict of the Trial Court was given vide judgment dated 29.3.2005.All theaccused in the murder of the LA were let off by the court giving benefit of doubt infavour of the accused, for want of concrete evidence. The Trial Court observed severalloose ends in the presentation of case by the Prosecution. The manner in which the actof murder was committed clearly shows that the murder was a pre-planned act. Theinsurer referred to the Hon’ble Supreme Court’s judgment in Rita Devi & others Vs. M/sNew India Assurance Co. Ltd. Wherein the court held that the proximate cause ofmurder is to be looked into to decide whether a particular murder is to be treated as an‘Accident’ or not.This view of the Hon’ble Supreme Court of India was discussed at length by theHon’ble NCDRC while considering Appeal No.204 of 1999 in the case between PrithviRaj Bhandari Vs. LIC & Others. While delivering the judgment, the Hon’ble NationalCommission reiterated the view expressed by the Hon’ble Supreme Court and held thatintent of murder is the primary factor to decide whether a murder is to be treated as anaccident or not. It was also held by the Hon’ble Commission that though the accusedwas not found in the case, the decision to treat the case as murder simplicitor wasarrived at on the basis of the nature of injuries inflicted on the victim.As the case of the LA in the present case is not a case of indiscriminate killing, themurder amounts to ‘murder simplicitor’ and not an accidental murder. The decisiongiven by this office under Award No.G-94-2005-06 cannot be taken as an establishedcase law, as the core issue of complaint at that time was condonation of delay. Further,the latest judgment of NCDRC was pronounced subsequent to the award No.G-94-2005-06. Hence it was decided to dismiss the complaint.Kochi Ombudsman CentreCase No. : IO/KCH/LI/21-001-115/2006-07Shri.A.V.ShijuVsLife Insurance Corporation of IndiaAward Dated : 17.10.2006

The complaint under Rule 12(1)(b) read with Rule 13 of the RPG Rules, 1998 relates torepudiation of a life insurance claim by the respondent under Pol.No.782753481 heldby the mother of the complainant. The policy was issued on 7.12.2002 based on aproposal for insurance dated 1.12.2002 where under all health related questions wereanswered as if the life assured was hale and hearty. However, the life assured died on12.5.2005 due to multiple Myeloma, CAD and Cardio-respiratory arrest. Theinvestigations conducted by the insurer proved that the life assured was diagnosed tobe suffering from Myeloma as early as in 2001 and it was further confirmed by theRegional Cancer Centre, Trivandrum in February 2002. The policy had commencedonly in December 2002. The life assured was an SSLC holder and it was improbablethat she was not aware of the seriousness of her problems. In any case, thesuppression of pre-proposal illness being very obvious, the insurer had repudiated theclaim. on going through the medical reports, this Forum also was convinced of the caseas true and therefore the action of the insurer in repudiating the claim was upheld. Thecomplaint was dismissed as devoid of merits.Kochi Ombudsman CentreCase No. : IO/KCH/LI/21-001-084/2006-07Smt.Lathika RamachandranVsLife Insurance Corporation of IndiaAward Dated : 26.10.2006The complaint under Rule 12(1)(b) read with Rule 13 of the RPG Rules, 1998 relates torepudiation of a life insurance claim by the insurer under Pol.No.392561123 held by thehusband of the complainant. The policy commenced in July 2002 and the life assureddied on 3.1.2005 at MCH Kottayam due to Diabetic nephropathy Grade V, acute renalfailure Type 2 Diabetes and Ischaemic heart disease. The Doctor of MCH Kottayam hadcertified that the life assured was suffering from Diabetes for the past 16 years. Hewas also reportedly under treatment at Mavelikkara before his admissions at MCHKottayam. In the proposal, all health related questions were answered as if the lifeassured was hale and hearty. The circumstances of the case being analysedobjectively, it was clear that all the these serious diseases could not have developed oraggravated all on a sudden and that the life assured was fully aware of them even atthe time of proposing for insurance. The suppression of material facts being very clear,the action of the insurer in repudiating the claim was upheld and the complaint wasdismissed.Kochi Ombudsman CentreCase No. : IO/KCH/LI/21-001-163/2006-07Sri.Kuriakose T.VsLife Insurance Corporation of IndiaAward Dated : 05.12.2006The complaint under Rule 12(1)(b) read with Rule 13 of the RPG Rules, 1998 relates tonon-payment of accident benefit under life insurance policy no.774269957 held by lateAlice K A, wife of the complainant. The policy was reportedly issued by the insurer inMarch 2003 without accident benefit and no loading for the said benefit was alsoincluded in the instalment premium. The life assured had died on 17.8.2005 in a trafficaccident. However, the proposal for insurance was on non-medical basis and the life

assured had suppressed two spells of medical history and hospitalisation forMyasthenia Gravis in 1999 and 2001. Even in such circumstances, considering the factthat the policy had run for nearly 2 ½ years, the insurer had paid the basic sumassured plus vested bonus on EX-GRATIA which the claimant had accepted in full andfinal settlement of all claims. The accident benefit was not payable as per the policyissued and, besides, the ex-gratia payment itself extinguished any further claim on thepolicy. In the circumstances, the complaint was found to be devoid of merits and thesame was dismissed.Kochi Ombudsman CentreCase No. : IO/KCH/LI/21-001-117/2006-07Smt.Dolly KuriakoseVsLife Insurance Corporation of IndiaAward Dated : 12.12.2006The complaint under Rule No.12(1)(b) read with Rule 13 of the RPG Rules, 1998relates to repudiation of a life insurance claim under Policy No. 773502618 held by thehusband of the complainant. The policy had commenced on 28.6.2000 and the samewas revived twice on 30.4.2003 and 26.7.2004 on the basis of declarations of goodhealth at the relevant points of time. All the same consequent on the death of the lifeassured on 28.3.2005, the investigations revealed that the life assured was sufferingfrom brain tumor right from April 2003 during which period of time, the first revival waseffected. From 27.4.2003 to 30.4.2003, the life assured was an inpatient at the JubileeMission Hospital, Trichur and the C.T.Scan done on 29.4.2003 had diagnosed theproblem as “low grade glioma in right frontal region”. In these circumstances, the claimwas repudiated for suppression of material facts at the time of revival. There was nopaid up value accrued on the policy as on the date of revival and therefore nothing waspayable to the complainant. In the circumstances of the case, the decision of theinsurer to repudiate the claim was found to be on solid grounds and hence the samewas upheld duly dismissing the complaint.Kochi Ombudsman CentreCase No. : IO/KCH/LI/21-001-180/2006-07Smt.Ramla BeeviVsLife Insurance Corporation of IndiaAward Dated : 12.12.2006The complaint under Rule 12(1)(b) read with Rule 13 of the RPG Rules, 1998 relates torepudiation of a life insurance claim under Pol.No.781485988 held by the husband ofthe complainant. The policy had commenced on 10.6.98 and it was revived on19.10.2005 by paying 7 quarterly premia cumulatively. The revival was supported by aMedical report and a personal statement of health. The life assured died on 30.10.2005and from the investigations and reports received from Medical College,Thiruvananthapuram, it was revealed that the life assured was suffering fromHypertension and Diabetes since 1 year and chronic kidney disease for 1 ½ months.Haemodialysis was also done on 15.10.2005. All these facts were not mentioned in thepersonal statement of health, which, as per the complainant was written out by theagent. The insurer had initiated action against the agent as well as the MedicalExaminer. However, although the life assured also should have been careful aboutwhatever was written out in the statement of health, as a lowly educated man, he could

not be blamed entirely. But, the misrepresentation of facts being of a very seriousnature, the revival repudiation alone by the insurer was upheld even while the insurerwas asked to reimburse 50% of the revival arrears paid on 19.10.2005 as ex-gratia, onhumanitarian grounds.Kochi Ombudsman CentreCase No. : IO/KCH/LI/21-001-219/2006-07Shri.K.BabuVs.Life Insurance Corporation of IndiaAward Dated : 31.1.2007The complaint under Rule 12(1)(b) read with Rule 13 of the RPG Rules, 1998 relates torevival repudiation of a life insurance claim under Pol.No.781785808 held by lateSmt.R.Bindu, wife of the complainant. The policy under Table & Term 125-20 hadcommenced from 9.7.99, but lapsed from April 2002 onwards. It was revived on28.6.2004 on the basis of a DGH which declared the life assured hale and hearty.However, the medical records obtained by the insured proved that the life assured wasa patient of tuberculosis meningitis right from 9.10.2003. She had inpatient treatmentsat ESI Hospital and the Medical College, Trivandrum. These details having been foundconcealed in the personal statement submitted for revival of the policy on 28.6.2004,the claim was repudiated by the insurer. However, on a closer scrutiny of the records,it was doubtful whether the life assured or her husband was really aware of the serioushealth problems of the life assured as they were very lowly educated and struggling fortheir livelihood. While the stand of the insurer in repudiating the claim was fullyjustified, as there were misrepresentations in the DGH, considering the pitiablecircumstances of the complainant and possible unintentional misrepresentations in theDGH, a small ex-gratia of Rs.3000/- was allowed even as the repudiation was upheld.Kochi Ombudsman CentreCase No. : IO/KCH/LI/21-002-186/2006-07Smt.Sujatha UdayanVs.SBI Life Insurance Co.Ltd.Award Dated : 31.1.2007The complaint under Rule 12(1)(b) read with Rule 13 of the RPG Rules, 1998 arose outof repudiation of a claim by the insurer under a Group Insurance policy coveringoutstanding housing loans of SBI Group customers. The complainant’s husband hadraised a loan from SBT, Kodannur and thus joined the above scheme based on a DGHwherein the life assured was declared healthy in all respects. When a claim arose, theinsurer had caused an investigation and found that the life assured was suffering fromcertain health problems which were not mentioned in the said DGH. The life assrueddied on 16.6.2005 due to Cirrhosis of liver, Hepatic encephalopathy etc. within a periodof 8 months and a few days after joining the scheme. The investigations by the insurerreportedly revealed that the life assured was suffering from Diabetes for the past sixyears. The medical certificate from AIMS Kochi stated that he was under treatmentfrom Nov.2003. However, the complainant maintained that although treatment forDiabetes was being taken for 2-3 years, conditions like Cirrhosis of liver and Hepaticencephalopathy were diagnosed only on admission into the hospital. Other than avague statement by the medical attendant and the Investigator, the insurer had notproduced any evidence to support their argument relating to concealment of a critical

illness by the life assured and hence the claim was allowed within the financial limits ofthe policy setting aside the repudiation.Kochi Ombudsman CentreCase No. : IO/KCH/LI/21-001-185/2006-07Smt.Judy FermineVs.Life Insurance Corporation of IndiaAward Dated : 01.2.2007The complaint under Rule 12(1)(b) read with Rule 13 of the RPG Rules, 1998 arose outof revival repudiation of a life insurance claim under Pol.No.773512167 held by thehusband of the complainant. The life assured died on 16.7.2004 due to Cardiopulmonaryarrest, septicaemia etc. at Lourdes hospital, Kochi. The policy had lapsedfrom Nov.2003 and it was revived on 26.5.2004 on the strength of a personal statementwhere under the life assured was declared to be hale and hearty. But, the investigationof early claim proved the facts to be otherwise. The life assured was an inpatient ofPVS Hospital, Kochi from 24.4.2004 to 5.5.2004 and again from 26.5.2004 to23.6.2004. The final diagnosis of the problem at the hospital was cirrhosis ofliver/portal hypertension/alcohol related disease and Diabetes. In fact, the second spellof admission of the life assured at PVS Hospital, Kochi was from 26.5.2004 and on thesame day the policy was revived on the strength of the DGH. The concealment ofmaterial facts being abundantly clear, the insurer had repudiated the revival. ThisForum found the action of the insurer justifiable in every respect and therefore thecomplaint was dismissed.Kochi Ombudsman CentreCase No. : IO/KCH/LI/21-001-253/2006-07Shri.K.G.Narayana KurupVs.Life Insurance Corporation of IndiaAward Dated : 07.03.2007The complaint under Rule 12(1)(b) read with Rule 13 of the RPG Rules, 1998 arose outof repudiation of a life insurance claim by the respondent under Pol. No. 391946562issued to Smt. Syamalamma - wife of the complainant. The life assured died on25.6.2005 while the policy had commenced only on 5.3.2004. The early claiminvestigations proved that the life assured was diagnosed of “carcinoma pancreas” atthe Lakeshore Hospital, Kochi on 23.2.2004 itself and since then she was undergoingvarious treatments including palliative therapy. The insurer had obtained all documentsfrom the hospital. The life assured was an employee of the Alappuzha Dist.Co.Op.BankLtd.and on 20.2.2004 she had applied for commutation leave from 23.2.2004 to28.2.2004 for the purpose of consultations at the hospital. The insurance proposal wassubmitted on 6.3.2004 suppressing all these serious health conditions and hence theclaim was repudiated by the insurer. On going through the records, it was revealed thatthe insurer had clinching evidence to substantiate the repudiation, which was thereforeupheld by this Forum as fully justifiable. The complaint was accordingly dismissed.Kochi Ombudsman CentreCase No. : IO/KCH/LI/21-001-251/2006-07Smt.Usha RamachandranVs

Life Insurance Corporation of IndiaAWARD DATED 08.03.2007The complaint under Rule 12(1)(b) read with Rule 13 of the RPG Rules, 1998 relates torepudiation of a life insurance claim by the insurer under Pol.No.391907728 held by thehusband of the complainant late Sri.Ramachandran. The deceased life assured was aCash Peon in the South Indian Bank and he was under treatment for hypertension forabout 20 years. The life assured expired on 29.6.2005 at the Amritha Hospital, Kochidue to complications arising out of renal failure, septicaemia and systemichypertension. The systemic hypertensive heart problem was detected by a Doctor evenas early as on 26.12.2003 whereas the insurance proposal was submitted on 15.7.2004without disclosing the serious health problems being suffered by the life assured. Theinsurer had conducted an investigation and they had solid proof to support therepudiation which was upheld by this Forum too. However, there were certainextenuating circumstances in the case. The widow was no in penury after the death ofher husband and her house itself is under threat of attachment by the creditors of herhusband. The complainant has two young daughters pursuing education and they haveno means of livelihood except for the meagre salary of her son. The earlier insurancepolicies of her husband were all surrendered during his life time. Considering theseagonizing circumstances, even while upholding the order of repudiation passed by theinsurer, this Forum allowed an ex-gratia of Rs.5000/- to the complainant under RuleNo.18 of the RPG Rules 1998 and the complaint was disposed of.Kochi Ombudsman CentreCase No. : IO/KCH/LI/21-001-245/2006-07Smt.BeenaVs.Life Insurance Corporation of IndiaAward Dated : 21.03.2007The complaint under Rule 12(1)(b) read with Rule 13 of the RPG Rules, 1998 relates torevival repudiation of a life insurance claim by the insurer under Pol.No.773030477held by the husband of the complainant. The policy had commenced from 15.12.1998and it was lapsed from 6/2003 due to non-payment of premium. The policy wassubsequently revived on 23.2.2004 on the basis of a personal statement regardinghealth dated 20.2.2004 whereunder the life assured had declared himself to be haleand hearty. However the facts of the case were otherwise. The early claiminvestigation due to revival had shown that the life assured was under treatment at theJubilee Mission Hospital, Trichur from 19.9.2003 for chronic renal failure. There were anumber of reports confirming the disease and treatment from 19.9.2003. All these factshaving been suppressed in the DGH, the insurer had repudiated the revival which wasfound fully justifiable by this Forum. However, the insured had offered the paid upvalue under the policy. The repudiation of the claim barring the paid-up value wastherefore upheld and the complaint was disposed of.Kolkata Ombudsman CentreCase No. : 184/21/001/L/06/06/07Shri Ashok BeraVsLife Insurance Corporation of IndiaAward Dated : 12.12.2006Facts & Submissions:

The complaint was regarding repudiation of death claim arising out of death of ShriGour Chandra Bera.Shri Ashok Bera was the nominee for the policy purchased by his father Shri GourChandra Bera from LICI. Policy No. 418204292 was purchased on 28.06.04 for Rs.70000/- and another policy no. 418187322 was purchased on 28.08.03 for Rs. 30000/-.The life assured expired on 06.09.04. LICI settled the claim under policy no.418187322 on 10.02.05 and paid the claim to Shri Ashok Bera, who was the nominee.However, the second policy, which was incepted on 28.06.04, was repudiated citingdeliberate misstatement in the proposal form and withholding of material information.The complainant appealed against the repudiation on 11.05.05, but LICI confirmed thedecision of repudiation on 16.09.05. Being aggrieved by the repudiation of LICI, thispetition was filed before this forum.The insurance company repudiated the claim on the following facts:i) The policy was an early claim (duration of the policy being 2 months 3 days) and thecause of death was CRF in a case of acute myocardial infarction.ii) The insurance company found that the DLA was a known Hypertensive patient andwas undergoing treatment since 02.01.04 (6 months before submission of proposal)at the OPD of Calcutta Medical College and Hospital. As these facts were notmentioned in the proposal form, the same was treated as suppression of materialfacts.As there were gaps in the claim of the complainant and the explanation given by theinsurance company, a hearing was fixed on 12.12.06, where both the complainant andthe officers from LICI attended.According to the complainant, his father was about 51 years old and due to a fall hewent to the OPOD of Calcutta Medical College as he was having generalized bodyache.He was treated for the bodyache. OPD tickets dated 02.01.04, 21.01.04 and 14.02.04indicated that the life assured was having a pain in the lumber region and he washaving difficulty in sitting and bending waist. His X-ray report revealed spondylosis cOster Ortho lumber scoliosis. The ticket also indicated that the life assured was aknown hypertensive and was on medication. And that he had severe low back pain fortwo weeks and radiation of pain in the lower limb.The complainant further stated that his father was admitted to the hospital on 06.09.04at 10.30 AM with chest pain, but unfortunately passed away at 11.10 AM on the sameday. The cause of death was CRF in a case of acute myocardial infarction. Accordingto him, his father died at an early age suddenly and the OPD treatment was takenduring the month of January’04 and the various opinions mentioned in the OPD ticketsshould not have been used for repudiation of the claim as he died of myocardialinfarction.On the other hand, the insurance company insisted on the information written bydoctors on the OPD ticket for the period 02.01.04 to 21.01.04 as sacrosanct. The entireepisode was based on these OPD tickets. To reiterate the main points for repudiation,it could be seen that the sentence written by doctors with regard to known hypertensiveand on medication was treated as the reason for ultimate death due to myocardialinfarction. The failure to indicate the pre-existence of disease in the proposal for thesecond policy, which was incepted on 28.06.04, was the main ground for repudiation ofthe claim.Further, during the course of hearing a question arose how another policy, which wastaken on 28.08.03 i.e., about 9 months back, was settled and claim was paid.According to the insurance authorities, the information with regard to the DLA being

hypertensive before the inception of the first policy was available and the same wasnot available before the inception of the second policy. They further stated that LICIdepended on the statement made in the OPD tickets that the life assured was a knownpatient of hypertensive and was on medication for treatment of hypertension.Treating the above as non-disclosure of material information at proposal stage, thecase was repudiated by the Divisional authority and later upheld by the Zonal authority.Decision:On going through the facts pertaining to both the policies, it was seen that the firstpolicy was settled due to lack of information with regard to the pre-existing nature ofthe various diseases suffered by the deceased life assured (DLA). By the time thesecond policy was scrutinized, the insurance authorities obtained an OPD ticket andthe analysis, which indicated that the DLA was suffering from hypertension and was onmedication. Whether there could be a connection between the continuous hypertensionor not at the time of taking the second policy, the life assured could have mentioned inthe proposal about his fall, about medication he had been taking for hypertension,which could have then given a proper understanding of the case before the policy isunderwritten. Therefore, keeping in view the totality of the circumstances and the earlydeath of the life assured, it is held that there could have been a continuous case ofhypertension and the accidental fall would have compounded the problems with regardto hypertension and, therefore, had a sudden attack of CRF in a case of myocardialinfarction. From this analysis, it is clear that the proposal form did not contain materialinformation for coming to a proper conclusion with regard to issuance of policy. We donot have any other alternative but to confirm the repudiation made by the insurancecompany on the ground of non-disclosure of material information at the proposal stage.Accordingly, the complaint is dismissed without any relief to the complainant.Kolkata Ombudsman CentreCase No. : 112/21/001/L/05/2006-07Smt. Shiela MahajanVsLife Insurance Corporation of IndiaAward Dated : 20.12.2006Facts & Submissions:The complaint was regarding repudiation of death claim on the ground of nondisclosureof material fact by the proposer under the policy by Life InsuranceCorporation of India.The complainant, Smt. Shiela Mahajan filed a death claim against the policyno.435044248 taken by her husband, late Raj Mahajan who expired on 18.8.2004 dueto sudden cardiac arrest.Late Raj Mahajan took the said policy with date of commencement on 28.7.2003 fromLICI. According to LICI, Howrah D. O., the deceased’s wife submitted her claim on28.9.2004, which was repudiated fully by the concerned Division on 15.12.2004 on theground that they had sufficient proof to suggest that the DLA suffered from Diabetesand Hypertension for the last two years. This was not disclosed in the personal historycolumn of the proposal form by the Insured at the material time. Therefore, it may betreated as ‘suppression of material fact’ before taking the policy. The complainant,thereafter represented against the decision of the LICI and requested for a review ofthe claim stating that her husband was admitted to the hospital on 18.8.2004 at around

2 P. M. in an unconscious state and he expired within half-hour from admission withoutmuch treatment to offer. In spite of her representation, LICI repudiated the claim.LICI/Howrah D.O. furnished SCN on 7.9.2006 along with a copy of proposalform/papers and underwriting decision. They also submitted a death certificate dt.8.11.2004 issued by the attending doctor, Dr. Tanvir Momen, which is reproduced asunder :-“ This is to say that the deceased patient has been under my treatment for the last 2years as a patient. He was suffering from mild Diabetes and Hypertension. He was alsotreated by me for Fracture of the Hip in January 4 th , 2004.He was admitted on 18/8/04 with sudden Acute Chest pain due to Massive MyocardialInfarction and he passed away on 18/8/04 due to Cardiac Arrest. Contact me if youhave any more queries.”LICI categorically mentioned in their SCN dt.7.9.2006 that in the Personal HistoryColumn of the Proposal Form, it has been found that the complainant has providedfalse and incorrect answers which evidently established that the deceased life assured(DLA) had a past history of suffering from Diabetes Mellitus and Hypertension prior tothe date of commencement of the policy.As there were communication gap between the LICI and the complainant in respect ofthe evidences provided by them, a hearing was held on 19.12.2006.Both the parties attended in the hearing, as scheduled, and their views were heard atthe time of hearing. During hearing process, Smt. Mahajan stated that the proposalwas signed by her late husband, Shri R. Mahajan at the time of taking the policy andhe was in good state of health and was not suffering from any diabetes orhypertension. However, the LICI authorities have obtained a certificate from Dr. TanvirMomen, which stated that the patient was under his treatment for the last two yearsand he was suffering from mild diabetes and hypertension. The patient was alsotreated for the fracture in the hip in 4 th January, 2004. When this was shown to her(Smt. Mahajan), she was surprised that the doctor, who treated for the fracture in thehip, mentioned about the fact that her husband was under his treatment for the last twoyears and was suffering from mild diabetes and hypertension. Therefore, she wasinformed that the proposal form obviously did not mention these facts. The complainantshowed total ignorance of the fact of misrepresentation in the proposal form.Under the circumstances, we hold that the proposal form has not been properly filled-inwith regard to the Personal History Column that he was suffering from any diabetesand hypertension for the last two year and therefore, this fact might definitely bematerial and prudent to the underwriter to decide the merit of the proposal and shouldhave been disclosed in the proposal form at the time of taking the policy.Under the circumstances, the decision of the Insurance Company to repudiate theclaim was justified and it was upheld.Kolkata Ombudsman CentreCase No. : 894/24/003/L/03/05-06Shri Rajeshwar Prasad JaiswalVsTata AIG Life Insurance Company Ltd.Award Dated : 21.12.2006Facts & Submissions:Shri Rajeshwar Prasad, S/o Late Radhe Prasad, in his complaint dated 22.03.06 statedthat his father Late Radhe Prasad took a policy from Tata AIG Life Insurance Company

Ltd and expired on 30.09.04. Therefore, he submitted claim forms for settlement ofdeath claim. Before the policy was issued, the insurance company had accepted theproposal on the basis of an affidavit given by the DLA with regard to the age. Onreceipt of claim papers, the insurance company declined to settle the claim allegingthere was a mistake in the statement of actual age of deceased life assured (DLA) withregard to the age. On receipt of the claim papers, the insurance company declined tosettle the claim alleging there was a mistake in the statement of actual age of DLA atthe time of purchasing the policy. Hence, this grievance.The insurance company in their self-contained note stated that the correct age of lifeassured at the time of issue of the policy was 68 years and not 54 years as declared inthe application. As the actual age was relevant to the risk associated as well as forunderwriting consideration, the claim was repudiated. The insurance company furtheradded that the policy would not have been issued to the DLA as the policy could begiven only for persons of age below 55 years. They also sought a hearing before theorder is issued. Keeping in view their request, a hearing was fixed on 21.12.06 andboth the complainant and the representatives of the insurance company appeared.The claimant relied on the EPIC issued by the Election Commission of India whereinthe age of the DLA has been mentioned. The card was issued on 06.03.1995 andaccording to him, this was good enough evidence to prove that the DLA has not fudgedhis age in the proposal form. The insurance authorities relied on the prescription givenby Dr. V. Prasad after the date of death wherein he stated that the age of the diseasedwas 70 years. According to the insurance authorities, the doctor wrote this from theinformation available in his records, which were not shown to the insurance authorities.The same doctor gave another certificate on 25.01.2005, one year after the date ofdeath in which he stated as per his opinion the age of the DLA was 68 years appx. Theinsurance authorities heavily relied on these two certificates.It may be pertinent here to state that the insurance company had accepted theproposal on the basis of an affidavit given by the insured and the policy could betreated as non-standard in respect of proof of age. When asked for why a copy of theEPIC was not taken into consideration at the time of issuing the policy, the insuranceauthority stated that the EPIC was not acceptable proof at that time. Now they havechanged their condition and Election Card can be accepted as a proof of age.During the course of hearing, it was found that the claimant has three sisters, oneelder to him and the others younger to him. It was also found that DLA’s wife was thenominee of the policy, who expired on 05.02.2005. The claim made by the complainantwas bonafide, as he felt that he would be the successor of the property of thedeceased. There was no evidence to show that the insurance company has questionedthe claim of the son. When this question was asked, the representatives of theinsurance company stated that the repudiation on the basis of doctor’s certificate wasfinal and, therefore, they did not bother to get into the finer points of the claim of thecomplainant.Decision:On going through the evidence and discussions made during the hearing, we came to aconclusion that the age mentioned in the Election Card issued in 1995 should be takenas sufficient proof. The contradictory statements made by Dr. V. Prasad wherein heissued certificates after the death of the deceased could not be accepted as goodevidence. Therefore, the repudiation made on the evidence of doctor’s certificate couldnot be sustained. Hence, the insurance company were directed to settle the claim ofthe complainant keeping in view the various other legal formalities required.

Kolkata Ombudsman CentreCase No. : 404/21/001/L/08/06-07Smt. Puspa SutradharVsLife Insurance Corporation of IndiaAward Dated : 26.12.2006Facts & Submissions:Smt. Puspa Sutradhar, w/o Late Bachchu Sutradhar, DLA, made a claim on the LICpolicy purchased by her husband. The DLA died on 15.05.2002. The claim wasrepudiated by LICI on 04.03.2006. She made further representation to the Zonal Office,but they also turned down her appeal. Being aggrieved, she filed this petition.The insurance company sent a self-contained note along with the death certificate fromthe hospital, copy of premium receipt dated 15.05.02, MR dated 14.05.02 and form no.680 signed by the DLA on 15.05.02.From the self-contained note it could be seen that the repudiation was based on theground of submission of false documents. The premium payment was stopped by theDLA from May 2001 and as per rules the policy became lapsed w.e.f. November 2001.According to the documents available, the DLA seemed to have submitted form no. 680for revival on 15.05.02 by paying Rs.2,368/- (cash transaction no. 8586 dated 15.05.02 at 11.34 AM) and also submittedmedical report signed by the DLA on 14.05.02, one agent and one panel doctor Dr.S.K.Keshri. However, it was confirmed that the DLA expired on that very day on15.05.02 at 5.10 PM at Sub Divisional Hospital. The death certificate dated 06.06.02issued by the SD Hospital, Rampurhat showed that the DLA was under treatment of Dr.A.Banerjee in the Male Surgery Ward of that hospital from 08.05.02 to 15.05.02 andexpired in a case of CRF after being operated for Duodenal Perforation. Revival madeon the strength of Declaration of Good Health when the life assured was hospitalizedwas not valid as per the insurance company. Similarly, a patient admitted in thehospital for surgical operation furnishing Good Health declaration certificate by anotherprivate doctor during the period of revival of insurance policy cannot be acceptable.Therefore, the insurance company contended that the revival was done under falsecertification and the claim was not settled.Decision :From the above information available along with the documents, it could be easily seenthat a medical report was obtained on 14.05.02 and premium was paid in cash on15.05.02 at 11.34 AM indicate that persons were in a hurry to get the policy revived.The fact that the life assured died on the very same day when the premium for thepolicy was obtained indicates that questionable methods were adopted to revive thepolicy. Also the fact that Good Health certificate given by a doctor, who is notconnected with the in-patient, who was in the bed due to operation for duodenalperforation was also not acceptable. LICI functions with utmost Good Faith and,therefore, taking advantage by producing a medical certificate that ought not to havebeen issued for getting the revival of the policy is not acceptable. Under thesecircumstances, it was held that repudiation decision taken by LICI was justified andaccordingly, it was upheld.Kolkata Ombudsman CentreCase No. : 450/21/008/L/09/2006-2007Shri Gouranga GhoshVs

Kotak Mohindra Old Mutual Life Insurance Ltd.Award Dated : 12.01.07Facts & Submissions :This petition was filed by the complainant for non-settlement of death claim due to nonproductionof required documents to the insurance company.The complainant, Shri Gouranga Ghosh was the nominee of late Smt. Ganga Ghoshwho purchased one policy with D.O.C. 24.12.2004. She expired on 27.03.2005. Theclaim papers were submitted to the insurance company through their authorized agent.On 12.10.2005, the complainant received another Form from the Insurer, which he dulyfilled up and sent to the Insurance Company along with Xerox copies of prescriptionand cash memos etc. Meanwhile, one Rupen Kumar Nag introducing himself asrepresentative of the Insurer took away the originals from the complainant’s son statingthese were required by the Insurance Company. There was no documentary evidenceto prove this incident. Since there was no reply from the insurance company, thecomplainant sent an Advocate’s Notice to the Insurance Company on 6.2.2006. Asthere was no reply from the Insurance Company, he came to this forum for redressal.The Insurance Company sent a letter dt.13.11.2006 in which they stated that they werenot yet repudiated the claim. They stated that the complainant was asked to send therequisite documents and hospital treatment particulars to settle the claim. According tothem, the complainant did not submit the relevant documents till date. In the absenceof complete documentation, the Insurance Company stated that they would not be ableto assess the claim in fair and appropriate manner.Decision :Since, the claim had not yet been repudiated and the insurance authorities statedduring the course of hearing that they would collect the required documents from thehospital authorities etc., this office directed the insurance authorities to do the needfulimmediately and settle the claim.Kolkata Ombudsman CentreCase No. : 892/21/009/L/03/05-06Smt. Rajkumari DeviVsBajaj Allianz Life Insurance Company Ltd.Award Dated : 31.01.07Facts & Submissions:Smt. Rajkumar Devi, in her petition stated that her husband Shri Damodar Sah expiredon 26.04.04 due to cardiac failure after suffering from Diarrhoea. Her late husbandpurchased a policy from Bajaj Allianz Life Insurance Company Ltd. with DOC 22.03.04for sum assured Rs. 2 lakhs. She filed a claim for settlement vide her letter dated21.06.05 but the insurance company observed that the DLA had taken treatment forProstrate Gland problem 2 years back and the same was not disclosed in the proposalform. In the petition Smt. Rajkumari Devi stated that her husband never suffered fromsuch disease and the proposal form was correctly filled in and that the allegation madeby the insurer was false. She further sent a medical attendant’s certificate issued byDr. S.K.Sinha. As per the certificate Dr. Sinha treated the DLA at the time of death. Hisprescription was available and he certified that the patient’s condition did not permitpathological investigation and the patient died due to cardiac failure arising out ofDiarrhoea.

The insurance company in their self-contained note stated that the death occurredwithin 1 month 4 days from the DOC and the repudiation was done on the ground of“Suppression of material facts”, which they found out from the investigation and writtenstatement of the complainant and her son.Since there were doubts about the evidence available and the reasons for repudiationof the claim, a hearing was fixed. The complainant attended on the day of hearingwhile no person representing the insurance company attended on that day. There wasno letter seeking adjournment from the insurance company. This office proceeded withthe hearing to find out exactly what happened before the death of the deceased.HEARING :On filing the claim papers, the insurance authorities initiated the investigation of theclaim, as it was only 1 month 4 days old. They obtained 3 statements of the familymembers – Smt. Rajkumari Devi (wife), Shri Dileep Kumar (Son) and Shri RamawatarSah (Elder Brother) of the deceased. All of them mentioned treatment of ProstrateGland of the DLA 2 years before by a Homeopath Doctor from Muzaffarpur and thesame was fully cured. According to the insurance authorities, all the 3 statements werewritten and certified to having been read over, explained and admitted by thedeclarant, by one Shri K.Chakraborty, Investigating Officer. The wife and the brothersigned it in Hindi and the son signed in English.During the course of hearing, when questioned about these documents, thecomplainant i.e., wife of the DLA stated that the investigating officer took some signedblank papers from them and recorded what was mentioned in this certificate. Accordingto her, they did not know that the certificate contained the mention of the treatment ofone Prostate Gland by Dr. Ramji Dubey. Further, the investigating officer stated thatthe area was backward; there was poor accessibility to the village and there wasprevalence of Diarrhoea, heart attack and fever in the area. They also mentioned thatthe DLA was a respected person with no bad habits, having perfectly normal healthcondition. The DLA was treated by Dr. S.K.Sinha and died in the doctor’s chamber. Thereport of the investigating team also mentioned about one certificate dated 29.05.05 ofDr. R. Dubey of Muzaffarpur that he did not remember any previous history oftreatment of the DLA in absence of any old prescription. They also recommended therelease of the policy claim to the claimant.Although the Homeopath Doctor Dr. R.Dubey was named in the investigation report andstatement of family members, no certificate or prescription from him was furnishedeither by the insurer or by the complainant. When the complainant was asked about theprescription, she stated that few years before the death, her husband took a neighbourwith him to the Doctor and actually the neighbour was suffering from Prostrate Glandproblem, which was cured by that doctor. It is natural that the DLA does not have anyprescription from the doctor.It was also found from the record that the insurance company not being satisfied by theinvestigation report, got another enquiry conducted by Snippers India Ltd., whonegated the earlier report. However, they stated that the DLA had no moral hazards butmight have suffered from some old disease, hidden from his family members andneighbours. However, there was no documentary proof to substantiate it. It was alsofound that the insurer advised the proposer to undergo some tests viz., CBC, ESR,FBS, Cholesterol, HIV, Tele & ECG, but this office has not been furnished with anymedical test results, which was conducted before accepting the proposal. In theabsence of any representation from the insurance company, this office was unable tocome to a conclusion whether there was any adverse report from the medical tests.Decision :

We may mention that the insurance company did not attend the hearing fixed nor gaveany reason for non-attendance. This office has to put on record that this type ofbehaviour cannot be tolerated before a senior quasi-judiciary authority. The higherauthorities of the insurance company would henceforth ensure that there is a firmcompliance to the notice issued by this office.From the evidence available on record and from the answers given during the course ofhearing from the complainant, it could be easily presumed that Dr. R. Dubey,Homeopath from Muzaffarpur did not have any prescription of the DLA before hepassed away and the insurance company could not conclusively prove that the DLAwas treated for Prostrate Gland by him. It is clear that the DLA died of cardiac failuredue to diarrhoea, which existed in the area he was living. It is also certified by both theinvestigators that the DLA did not have any bad habit. The statement made by the 2 ndinvestigator in his report that the DLA might have suffered from some old diseasecannot be taken as having evidential value. We, therefore, came to a conclusion thatthere was no misrepresentation in the proposal form made by the DLA before takingthe policy. Accordingly, the insurance company were directed to settle the claim for Rs.2,00,000/- (Rupees two lakhs) only.Kolkata Ombudsman CentreCase No. : 153/21/001/L/06/06-07Smt. Bijoya BiswasVsLife Insurance Corporation of IndiaAward Dated : 31.01.07Facts & Submissions :We dealt with two complaints, but since the nature of complaint and the complainant inboth the cases were same, we proceeded to deal with the complaints as follows:Smt. Bijoya Biswas, wife of Late Tapan Kumar Biswas, filed a petition that LICI did notsettle the death claim of the policies purchased by her deceased husband for sumassured of Rs. 20,000/- with DOC 28.06.01 and Rs. 25,000/- with DOC 28.06.02. ShriTapan Kumar Biswas, DLA died on 09.12.03. LICI repudiated the claim under both thepolicies vide their letter dated 29.03.04 stating that the proposer did not answer thequestion in the proposal form with regard to personal history correctly and the DLAsuffered from hypertension and was a known smoker for many years. The complainantappealed to the insurance company for review but the same was denied.The insurance company in their self-contained note stated that the DLA died ofmyocardial infarction. The duration of the illness was only 6 days. The Case HistorySheet of Uma Medical Research Institute, Kolkata revealed that the DLA was a knownhypertensive, a known smoker for many years and had a history of Duodenal Ulcer withupper GI Bleeding 15 years back.A hearing was fixed calling the complainant and the officials from the insurancecompany.HEARING :During the course of hearing, the complainant Smt. Bijoya Biswas stated that herhusband was a primary School Teacher, who did not have the habit of smoking and didnot suffer from any hypertension during the period of her marriage for 17 years. Fewdays before his death i.e., on 04.12.03, he complained of pain and went to the hospitalwherein he was admitted and her husband’s brother gave some statement to thehospital authorities without her knowledge and subsequently her husband passed away

on 09.12.2003. The medical attendant’s statement indicated that he was treated by onedoctor Dr. Santanu Acharyya on 02.12.03 and the Case History Sheet was reported tothe doctor by the brother of the patient Shri Swapan Kumar Biswas. She, therefore,pleaded that the statement made in the History Sheet of Uma Medical ResearchInstitute should not be taken as final. Question Nos. 11(a), 11(e), 11(f) and 11(i) werecorrectly answered with the available knowledge at the time of taking the policies.The representative from the insurance company stated that the repudiation was basedon the History Sheet submitted by the hospital and from the information in the HistorySheet it could be seen that the questionnaire in the proposal form had not beenproperly answered and, therefore, there was non-disclosure of material information atthe proposal stage.Decision :On going through the evidence and the facts that have been stated by the complainantduring the hearing, it could be surmised that the DLA did not smoke or did not haveany hypertension as per his wife’s statement during the period of marriage for 17years. The History Sheet given by Uma Medical Research Institute mentioned in thecertificate of hospital treatment, proforma belonging to the LICI, stated that all materialfacts had been reported by the patient and his relatives, particularly by his brother ShriSwapan Kumar Biswas. Since the patient was admitted on 04.12.03, it may besurmised that the case history had been given to the hospital authorities by his brother.When the question was asked about this, Smt. Bijoya Biswas stated that she wassitting outside the doctor’s room while her brother in law went and gave details ofhistory when her husband was admitted in the hospital. The insurance company got aninvestigation report prepared, which is known as Claim Enquiry Report and accordingto that report, the DLA was a primary school teacher having good health and died atthe age of 51 years. The report also suggested that the claim may be admitted. Whilepreparing the report, they obtained reports from neighbours and friends viz., Shri AshitBaran Rakhit, residing nearby. He gave a certificate as the deceased was possessing asound health and was attached with several social activities. Similar certificate wasalso given by one Shri Ratan Kumar Das. Another doctor Dr. T.C.Chakraborty, knownto the DLA, also gave similar certificate stating that he was in good health and activelyparticipated in social and cultural activities. Claim Enquiry Report and the certificateshave not been taken into consideration by the insurance company when theyrepudiated the claim. They solely based on the sentence, which was written by thehospital authorities in their Case History Sheet, which is reproduced below:“Known hypertensive – On stamlo; Known smoker for many years;H/o Duodenal Ulcer – with upper GI bleed approximately 15 yrs. Ago”The History Sheet was a record of whatever that has been said by a third party, in thiscase being the brother of the DLA and it is not a conclusion drawn by doctors from thediagnostic information available just before the time of death like pathological tests andother tests. The clinical examination indicated that the BP was 120/80 and, therefore,the conclusion drawn that the patient had a history of hypertension shows that thehospital authorities did not come to any conclusion with regard to pre-existinghypertension. Duodenal ulcer reported in the History Sheet is about 15 years old andaccording to the complainant, she was married for 17 years and that her husband hadnever faced this problem. Probably, Duodenal ulcer was before the marriage and thefigure 15 must have been an estimate made by third party while giving the details.Therefore, basing on this one statement for a patient, who died at a relatively youngage of 51 years due to cardiac failure and denying the claims made on the policiesseems to be totally illogical. The insurance authorities should have found out more

evidence to prove that the DLA was having continuous hypertension and was a smoker.Now, coming back to the question 11(a) with regard to any treatment during the last 5years, the DLA stated that there was no treatment. To the contrary, the insuranceauthorities probably, relied on the only fact that the deceased suffered duodenal ulcer15 years back. Though they asked for medical leave details from the employer, theemployer at the first instance did not give the details in the last 5 years. However, at alater stage, the school authorities sent a certificate that the DLA did not take any leaveon medical ground since 1999 until his death. This proves that the answer given to thequery was correct. In the case of question no. 11(e), definitely the patient did notsuffer from any disease mentioned therein. Therefore, saying “No” is taken to becorrect. With regard to query 11(h)(iv), whether the DLA used inter-alia tobacco in anyform, the answer was given as “No” and the insurance authorities found that theanswer was not correct due to a sentence recorded in the History Sheet of the Hospitalauthorities, which is nothing but a hearsay. So, this could not be treated as deliberateincorrect statement made by the deceased while taking the policy. Answer to questionno. 11(i) with regard to state of health was also correctly answered and no adverseinference need be taken.Therefore, the basis on which repudiation was made i.e., withholding of materialinformation with regard to health and habit for effecting the insurance has not beenconclusively proved by the LICI authorities. On the other hand, from the discussionsmentioned above, we tend to agree that quoting statements given in the history sheetby a third party, which do not have any diagnostic sanction, cannot be taken as a basefor treating the answers given as deliberate misrepresentation before the insuranceauthorities with regard to health and habit for repudiation of the claim.It was felt that the deceased while taking the policy was in good health and did notsuffer from any ailment and he was not in the knowledge of any ailment, which couldlead to his death by cardio respiratory failure – extensive anterior wall myocardialinfarction. We were of the opinion that LICI authorities should have taken more carebefore repudiating the claim to a widow. Accordingly, the insurance company weredirected to settle the claim under the aforesaid policies.Kolkata Ombudsman CentreCase No. : 457/21/001/L/09/06-07Smt. Vijay Laxmi PanigrahiVsLife Insurance Corporation of IndiaAward Dated : 02.02.07Facts & Submissions:This was a complaint regarding repudiation of death claim by LICI. This petition hasbeen admitted under Rule 12(1)(b) of RPG Rules 1998.The complainant, Smt. Vijay Laxmi Panigrahi, wife of Late Prasad Panigrahi, being thenominee of the deceased life assured (DLA) preferred a claim on 16.05.06 after thedemise of her husband on 25.02.06. According to her, the claim was repudiated by theinsurance company on the wrong interpretation of period of radiotherapy. She statedthat the doctor attested the correct period of radiotherapy and the same had beenenclosed with the complaint made to the office of the Insurance Ombudsman. Shestated that the attested copy was also sent to the insurance authorities and in spite ofseveral reminders and constant follow-up, the LICI authorities did not respond. Thispetition has been filed for redressal of the above stated grievance of repudiation of thedeath claim.

In the self-contained note, the insurance company stated that the DLA was abusinessman, who took a policy for sum assured of Rs. 50,000/- with DOC 11.11.2003.After a lapse of about 2 years 3 months, the insured died of cancer at his residence.The insurance company further stated they have evidence before them in the form oftreatment papers given by Acharya Harihara Regional Cancer Centre, Cuttack,according to which the DLA suffered from cancer in the cheek and had undergoneradiotherapy (15 sittings) from 04.07.03, but the insured did not disclose these facts inthe proposal form as could be observed from the answers given to question nos. 11(a),11(b), 11(c), 11(d), 11(e) and 11(i). LICI, therefore, stated that the DLA suppressedmaterial information while submitting the proposal form. Since the contract between theLICI and the insured was of utmost good faith and as there was no full disclosure, theinsurance company treated it as misrepresentation made by the DLA and repudiatedthe claim.Decision :On going through the evidence submitted by the complainant, it could be seen that thedeceased had undergone radiotherapy between 04.07.05 to 27.07.05, obviously thedoctor attending on the deceased has corrected the discharge certificate from 04.07.03to 04.07.05. We do not know whether this had been taken into consideration by theinsurance company before deciding on the repudiation. The complainant vehementlyclaimed that the cancer was detected only after 27.05.05 and that the patient wasdischarged originally on 06.06.05 and that he took radiotherapy from 04.07.05 to27.07.05 and, therefore, the disease could not have existed prior to signing theproposal form.As there was contradictory evidence with regard to the period of radiotherapy, it wouldbe fair if the insurance company gets the discharge certificate and other hospitaldocuments verified and then decide about the repudiation of the claim. Accordingly, theinsurance company were directed to review the repudiation by instituting aninvestigation into the claim of the complainant that there has been a mistake inmentioning the duration of radiotherapy and decide the claim on merit.Kolkata Ombudsman CentreCase No. : 674/24/003/L/01/05-06Smt. Purnima JanaVsTata AIG Life Insurance Company Ltd.Award Dated : 13.02.07Facts & Submissions :This petition was filed by the complainant Smt. Purnima Jana against repudiation ofdeath claim by Tata AIG Life Insurance Company Ltd.Shri Supriya Jana, deceased life assured (DLA), purchased an insurance policy withIssue Date 29.11.2003 from Tata AIG Life Insurance Company Ltd. He expired on10.04.2004, the duration of policy being 4 months 11 days. The complainant Smt.Purnima Jana, wife and nominee of the DLA, filed a death claim, but the insurancecompany repudiated the same as there was misrepresentation and non-disclosure offacts in the proposal form. Being aggrieved, the complainant filed this petition andstated that repudiation on the ground of chronic alcoholism could not be the reason forrepudiating the claim for misrepresentation of facts in the proposal form.

The insurance company in their self-contained note stated that they have irrefutableevidence before them for repudiating the death claim of the complainant. The DLA hada CT Scan Report dated 03.11.1999 and the report stated that he was having difficultyin writing. They also submitted proof of discharge certificate, which stated that thepatient was chronic alcoholic and was treated for convulsion and alcoholism. As thesefacts were not brought on record at the time of proposal, the insurance companycontended that the proposer did not submit correct details and, therefore, they treatedit as misrepresentation and repudiated the claim.HEARING :A hearing was fixed where representatives of the insurance company and thecomplainant attended. During the hearing, the complainant stated that her husbandwas not alcoholic and, therefore, the reason for repudiation was not correct.On the other hand, the representative of the insurance company stated that they havefurther evidence in the form of a statement given by the mother of the DLA, whichclearly stated that her son was alcoholic. The DLA also submitted application for leaveon medical ground for treatment to his employer (alcoholism reported in medicalprescription and DLA’s employer cautioned him for delinquent behaviour). The dateswherein he had treatment with regard to alcoholism and convulsion, CT Scan etc. fallbefore the inception of the policy. The representative of the insurance company,therefore, stated that there was misrepresentation in the proposal form as the insuredhad declared that he was fit at the time of taking the policy and hence, the repudiationdecision was correct.Decision :From the above evidence, it was clear that the insurance company investigated theearly death claim thoroughly and found that the insured was alcoholic and wasregularly taking leave for medical treatment and that he was in the knowledge ofhospitalization and his own disease, which were not disclosed in the proposal form.The arguments given by the complainant were not tenable. We, therefore, had noalternative but to agree with the insurance company and confirmed the repudiationmade by them with regard to death claim. The order was passed without any relief tothe complainant.Kolkata Ombudsman CentreCase No. : 616/24/001/L/11/06-07Sk. Rabial HossainVsLife Insurance Corporation of IndiaAward Dated : 14.02.2007Facts & Submissions :This was a petition filed by the complainant SK Rabial Hossain for delay in settlementof death claim by LICI.SK Rabial Hossain was the nominee of the deceased life assured (DLA) SK Jehangir.SK Jehangir died in a road accident on 10.01.2006 at Asansol. The nominee lodged aclaim on 16.08.06 with all relevant documents. The complainant further stated that theDOC as per First Premium Receipt (FPR) was 27.12.04 and the DOC as per renewalreceipt was 28.11.04. According to him, if the DOC is shifted to 27.12.04, the claimwould have been admissible. In spite of written reminders, the claim was not settled.Hence this petition for relief.

In the self-contained note the insurance company stated that the proposer signed theproposal form on 27.12.2004 and opted for back dating of the risk to 28.11.2004.Originally the proposal was accepted as risk date 27.12.2004 and after the proposersent a letter dated 18.01.05, the risk date was corrected from 27.12.04 to 28.11.04.The life assured died on 10.01.06 as per the death certificate submitted by theclaimant. As per the policy condition, the premiums are payable half yearly and thepremium has been paid up to 28.05.05 and, therefore, the policy was running with thecover up to 28.11.05. Had the DLA paid the premium before 27.12.05 for the next Halfyearlyperiod, the date of death would have fallen during the course of cover of thepolicy. Since the premium for hly. due in November’05 was not paid, according toinsurance company, only grace period was available, which was over by 27.12.05.Since the death occurred after that date i.e., on 10.01.06, the question of paying thedeath benefit did not arise.Decision :On going through the evidence available on record, it could be seen that the proposalwas dated 27.12.04 and the proposer opted for DOC of risk to be from 28.11.04, asback dating was permitted under the LICI Rules. However, inadvertently, the insurancecompany gave the date of risk from 27.12.04. The proposer did not keep quite butrequested LICI to change the DOC of risk from 27.12.04 to 28.11.04, which was dulycomplied by the LICI on 18.01.2005. The life assured paid hly. premium due on28.05.05 on 08.10.2005 and thereby the life cover was operative up to 28.11.05. Therewas no evidence to show that premium due 28.11.05 has been paid. Therefore, thegrace period comes into operation. Had he paid the premium before 27.12.05, thepolicy would have been in-force at the time of death of the life assured on 10.01.06.Now, coming to the argument of the complainant that the risk date should be taken as27.12.04, as was inadvertently done by the LICI, could not be accepted as it had beencorrected at the volition of the insured by his letter. Therefore, the grace period wouldstart only from 28.11.05 and not from 27.12.05. Under these circumstances, we wereunable to agree with the arguments of the complainant and accordingly, the petitionwas disposed without any relief to the complainant.Kolkata Ombudsman CentreCase No. : 423/21/001/L/09/06-07Shri Pradip Ranjan DeyVsLife Insurance Corporation of IndiaAward Dated : 20.02.07Facts & Submissions:This was a petition filed by Shri Pradip Ranjan Dey on repudiation of death claim byLICI.Smt. Smriti Dey, deceased life assured (DLA), a 36 year old self-employed lady,purchased a LICI policy for Rs. 1 lakh with DOC 23.04.03, date of proposal being30.06.03 and she expired on 24.01.04. Cause of death being CRF due to ruptureduterus in a case of terminated pregnancy.Shri Pradip Ranjan Dey, husband and nominee of the DLA, submitted claim forms toLICI, but the claim was repudiated due to suppression of fact of pregnancy whilesubmitting the proposal form. The claimant represented before the insuranceauthorities, but they confirmed the repudiation as the question no. 13(A) was notcorrectly answered. According to the complainant, his wife was not pregnant at the

time of taking the policy and that the medical report at the time of taking the policyincluded urine test. According to him, a person who had two successful deliverieswould not take an insurance cover with advance knowledge of pregnancy and that shewould die during the pregnancy. He relied on the decision of Hon’ble Supreme Court inthe case of Surender Singh and State of Punjab, in which it was stated “It may berecalled that this Court repeatedly observed that suspicion, however, grave cannot takethe place of legal proof”. In another case, the Apex Court observed “there isrequirement of proof and such requirement cannot be substituted by surmise andconjecture”. Further, the complainant furnished a certificate from Dr. A.K.Majhi dated08.06.06, which is reproduced below:“Bleeding may occur for early pregnancy cyclically or irregularly due to various reasons…. It may or may not be a serious complication and the patient may be confused toascertain it to be menstruation. As such she (DLA) might have confused of her earlypregnancy due to bleeding occurring on 24.06.03”(before submission of proposal)The insurance company in their self-contained note stated that the repudiation wasmade because of the delivery and ultimate death that took place, which indicated thatshe was pregnant nine months from that date, which fell before the date of proposal. Inthe proposal form, she mentioned that her menstruation cycle was on 24.06.03, whichaccording to them, was not correct and, therefore, question no. 13(A) was not correctlyanswered and it became suppression of material facts. Hence, repudiation took place.HEARING:A hearing was fixed. The complainant Shri Pradip Ranjan Dey could not attend due tounavoidable circumstances. However, the representatives of the insurance companyattended. They stated that they have irrefutable proof that Smt. Smriti Dey waspregnant before the inception of the policy. They gave a copy of the prescription dated01.08.03 given by Dr. A.K.Maji, in which he stated that Last Menstruation Period (LMP)was 24.04.03 while expected Date of Delivery (EDD) was 30.01.04. Similarly, there wasanother prescription dated 12.11.03 from the same doctor, in which it was mentionedthat the EDD was 30.01.04. According to the insurance authorities, this clearlyindicated that she was pregnant before signing of the proposal form.Decision:We proposed to dispose of the petition ex-parte on merits, as the complainant couldnot attend. On going through the evidence submitted by the insurance authorities, itwas clear that the very same doctor, who gave a certificate dated 08.06.06 (mentionedabove in para 3) had clearly written that the LMP was 24.04.03 and the EDD was30.01.04. This prescription given by him irrefutably proved that the deceased lady waspregnant before signing the proposal form and she had not mentioned the answer toquestion no. 13(A) correctly. This clearly showed that there was misrepresentation andsuppression of material facts. Since the policy is a contract of utmost good faith, wehad to agree with the repudiation made by the insurance company. Accordingly, theclaim was disposed of without any relief to the complainant.Kolkata Ombudsman CentreCase No. : 678/24/001/L/01/05-06Smt. Bharati KumariVsLife Insurance Corporation of IndiaAward Dated : 06.03.07Facts & Submissions:

This was a petition filed by Smt. Bharati Kumari for non-settlement of death claim onthe life of her father by LICI.Shri Ram Narayan Mahato, deceased life assured (DLA), purchased a policy with dateof commencement (DOC) 28.03.03. He expired on 18.12.03 and duration of the policywas 8 months 21 days. The cause of death was not mentioned in the claim form. All thedocuments were submitted to LICI, but even after 3 years the insurance company didnot settle her claim. Hence, this petition for relief.LICI, Muzaffarpur Division stated that the DLA had understated his age in the proposalform by 10 years. They also suspected that some tampering was done in the RationCard submitted by the DLA as another proof of actual age, as the original policy wasissued as a non-standard policy. In the self-contained note, LICI informed that theycould not take any decision with regard to the claim, as there was a doubt with regardto suppression of the actual age.HEARING :A hearing was fixed. None attended on behalf of the complainant while therepresentative of LICI attended. The representative of LICI was directed to take adecision with regard to claim and convey the same before 26.02.07.Decision :This office received a fax dated 20.02.07 from LICI, Muzaffarpur Division stating thatthey could not procure further evidence of suppression of age or ill health of the DLA.Therefore, they admitted the claim for basic sum assured in favour of the nominee. Thenominee also sent a letter dated 16.02.07 stating that she could not attend the hearingat Kolkata due to distance. Since LICI had already admitted the claim, we directed theinsurance company to settle the claim. We also requested the complainant to complywith the requirements of LICI.Kolkata Ombudsman CentreCase No. : 214/24/001/L/06/06-07Shri Padma Narain SinhaVsLife Insurance Corporation of IndiaAward Dated : 06.03.07Facts & Submissions :This was a petition filed by Shri Padma Narain Sinha for non-settlement of death claimby LICI.Shri Padma Narain Sinha filed his complaint for non-settlement of death claim on thepolicy taken on the life of his deceased wife Smt. Sumitra Devi, DLA. From the ‘P’ formand allied papers submitted by the complainant, it was found that the life assured diedon 15.06.1989 due to heart attack at the age of 49. The complainant did not furnish anyfurther detail.LICI did not furnish any self-contained note, but we find from the complainant’s ‘P’ formthat LICI sent a letter dated 12.02.1990 requesting the complainant to submit deathcertificate.HEARING :A hearing was fixed. Nobody attended on behalf of the complainant, whilerepresentatives of LICI attended. During the hearing, the representatives of LICI statedthat the complainant has been informed of the requirement with regard to the deathclaim and relevant forms have been issued through their agent and it is found that theclaimant has received the forms because he approached the Branch officials forassistance in filing the claim forms. It is understood that the complainant did not submit

the required papers and hence there was delay in settling the claim since LICI were notin a position to ascertain whether the claim is tenable or not. They further stated thatthough the policy docket was not available, there would not be any problem in settlingthe claim.Decision :It was found that the claim has been made long after the death of the life assured.Unless the forms are filed, as required by LICI, the claim could not be processed.Under these circumstances, we requested the complainant to cooperate with LICI infiling the required forms and LICI officials were directed to take up the matter withregard to allowability of the claim on submission of the documents. The complainant isat liberty to go to any other forum including this forum, if he is not satisfied with thedecision of LICI.Kolkata Ombudsman CentreCase No. : 180/24/001/L/06/06-07Shri Mahi Narayan JhaVsLife Insurance Corporation of IndiaAward Dated : 06.03.07Facts & Submissions:This was a petition filed by Shri Mahi Narayan Jha for non-settlement of death claim byLICI.Shri Viswanath Jha, deceased life assured (DLA), purchased an LIC policy no.534167808. Shri Mahi Narayan Jha, nominee and father of the DLA, submitted thedeath claim forms on 22.03.05 on the expiry of his son Late Viswanath Jha on15.09.04. He had been pursuing with the LICI authorities for settlement of death claim,but the claim was not settled. Hence, this petition was filed for redressal.LICI stated that the policy commenced on 28.07.03 and the duration of the policy wasless than 1 year 2 months. As the DLA was living in Noida, the insurance company didnot have the correct address. LICI entrusted Marketing Manager, Meerut DO to enquireinto the case and, therefore, no self-contained note could be filed.A hearing was fixed. Both the complainant and representatives of LICI attended.According to the representatives of LICI, delay occurred due to lack of proper addressand non-receipt of enquiry report. They further stated that on receipt of InvestigationReport (IR), they admitted the death claim for basic sum assured and additional sum asper policy conditions and sent the discharge voucher (DV) vide their letter dated26.02.07. The complainant, who was present at the time of hearing, was informed ofthis matter.Decision:The complainant was requested to return the DV duly executed immediately on receiptand LICI officials were requested to send the cheque immediately on receipt of DV. Asthe complaint was redressed to the satisfaction of the complainant, no further actionneed be taken.Kolkata Ombudsman CentreCase No. : 309/24/001/L/07/06-07Smt. Tillottama PrasadVsLife Insurance Corporation of India

Award Dated : 06.03.07Facts & Submissions:The complainant was the wife and nominee under Jeevan Akshay policy no. 530073801of her husband Late Shyam Sundar Prasad. The life assured expired on 09.10.05. Shefurnished a copy of letter dated 03.05.06 issued by LICI, Eastern Zonal Office showingreturn of unutilized annuity cheques and confirming exit action taken by them. Thedeath claim was, however, kept pending by the servicing branch. The complainant didnot submit ‘P’ form.HEARING :A hearing was fixed. The complainant did not attend, while representatives of LICIattended. During the hearing, the representatives of LICI produced evidence that theyhave settled the death claim for Rs. 14,280/- vide cheque no. 133216 dated 28.12.06.This is also confirmed by the order issued by the District Consumer Forum, which hasstated that the above petitioner does not have any complaint against LICI as they havesettled the claim.Decision :Under these circumstances, the petition filed by the complainant is deemed to havebeen settled and no further action need be taken as the complainant is satisfied by theredressal of the complaint.Kolkata Ombudsman CentreCase No. : 349/24/001/L/08/06-07Smt. Sudhain MahaliVsLife Insurance Corporation of IndiaAward Dated : 07.03.07Facts & Submissions :This was a petition filed by Smt. Sudhain Mahali for non-settlement of death claimunder Salary Saving Scheme (SSS) Policy on the life of her husband by LICI.Smt. Sudhain Mahali, wife of Late Somra Mahali, deceased life assured (DLA), andnominee made this petition for non-payment of death claim under SSS policy issued byLICI. Against her representation, she was informed that the policy had lapsed w.e.f.August’99 and nothing was payable. Hence, this petition was filed for relief.According to the insurance company, the policy was under SSS with DOC 28.09.1998.They enquired from the employer Jogesh Chandra Tea Estate with regard to premiumsthat have been deducted from the DLA’s salaries and remittance particulars and it wasfound that the premiums were deducted up to April, 2000 (DLA was killed on15.05.2000), but remittance was made only up to July 1999. The employer failed toremit premium deducted from salary due to paucity of funds. According to theinsurance company, since the employer was at fault, they regretted the same. Theinsurance company further stated that they sent the claim forms to the claimant andstated that they requested their competent authority to consider the claim as ex-gratia.According to them, the complainant has not yet submitted the claim forms.Decision :Death of the life assured was established and it was presumed that the insurer havenot denied the claim. As per the details mentioned above, the premiums were deductedup to April 2000 and, therefore, the policy was in-force at the time of death of the DLA.Though the claim was lodged after more than 3 years, the insurance company under

their own guidelines can consider the claim according to merit. It was found that theDLA was a Tea Garden employee, who died a violent death and, therefore, it was likelythat the completion of formalities have taken some time, as it was a case of allegedmurder. This was a reasonable ground for considering the allowability of the claim after3 years.Under these circumstances, the insurance company were directed to condone the delayand after receiving the required documents and after investigation, if any, weredirected to decide about the allowability of the claim and do the needful. Thecomplainant was requested to cooperate with the insurance company and submit therequired documentation.Kolkata Ombudsman CentreCase No. : 394/21/001/L/08/2006-07Hav. Md. Nazrul HoqueVsLife Insurance Corpn. of IndiaAward Dated : 07.03.07Facts & Submissions :This petition was filed by the complainant for repudiation of a death claim by the LICIauthorities.The complainant, Hav. Md. Nazrul Hoque was a NCO in the Indian Army whopurchased the policy for his wife with Sum Assured of Rs.32,000/- with riskcommencing on 27.9.2003 at the age of 27 years. The cause of death was found as‘NASOPHARYNGEAL CARCINOMA’. The complainant submitted Claim Forms and theInsurer repudiated the claim on 07.11.2005 on the ground of withholding materialinformation with regard to the previous treatment of Epistaxis or Nasal Bleeding in theyear 1998. The Zonal Authorities, of LICI, again rejected the complainant appealed forre-consideration of the same. He stated that his deceased wife maintained a good andnormal health and she never underwent hospitalisation excepting for delivery.However, she was treated for Sinusitis previously.The Insurance Company repudiated the claim on the ground that the Deceased LifeAssured had withheld the material information regarding her health at the time of fillingthe proposal form and as a result of which the policy was issued on the basis of thatinformation. According to the Insurance Company, the claim form itself indicated thatthe deceased was suffering from Nasal Bleeding and Epistaxis problem for the last 3years and that history sheet indicated that she was suffering from such disease since2001. Since the above facts were not disclosed in the proposal form, there was noalternative, but to repudiate the claim.Decision :On going through the Butterworths Medical Dictionary, it was found that Epistaxismeant for bleeding from the nose. It could happen due to local disease of the nasalpassage or some times, it could occur due to manifestation of the general disease, or itcould happen in the earlier stages of acute fever and some blood diseases and also itcould happen due to high blood pressure or it could happen from any other cause also.The deceased was only 27 years old and nasal bleeding frequently or now and thenprior to the inception of the policy did not indicate that cancer had entered into herbody. The claimant had sufficient insurance coverage and he had excellent treatmentfacilities in the Military Hospitals. This office did not think that she would misrepresentin the proposal form with regard to her health. Bleeding from the nose was quite normaldisease. It should not be mandatory on the part of the claimant to disclose it in the

proposal form. Under the circumstances, it was held that there was no evidence toestablish that cancer was existed prior to inception of the policy. Therefore, this officeheld that the arguments put forth by the insurance company that the claim was nottenable owing to pre-existence of the disease did not hold good. Therefore, theInsurance Company was directed to pay the claim, as per policy conditions.Kolkata Ombudsman CentreCase No. : 374/24/001/L/08/2006-07Smt.Rina MandalVsLife Insurance Corpn. of IndiaAward Dated : 07.03.07Facts & Submissions :This petition was filed by the complainant for non-settlement of death claim against theabove policy issued by Life Insurance Corpn. of India.The complainant, Smt.Rina Mandal, nominee and wife of the L/A, late Chitta RanjanMandal filed this death claim as her husband expired on 26.6.2004. The relevantdocuments viz. claim forms etc. were submitted to the LICI on 9.9.2004. Till then therewas no response from the LICI. Hence, this petition was filed for seeking relief beforethis forum.The Insurance Company did not send any self-contained note.Decision :The complainant was requested to submit the specific documents, as sought for, by theLICI authorities for processing the claim. Simultaneously, the LICI authorities weredirected to complete processing of the claim on receipt of the documents and informthe complainant accordingly.Kolkata Ombudsman CentreCase No. : 458/21/001/L/09/06-07Smt. Grace Clara KachhapVsLife Insurance Corporation of IndiaAward Dated : 08.03.07Facts & Submissions:This petition was filed by the complainant Smt. Grace Clara Kachhap with regard torepudiation of death claim under the policy on the life of her husband Late FardinandToppo, deceased life assured (DLA).Shri Fardinand Toppo purchased an insurance policy from LICI with date ofcommencement (DOC) 28.08.01. Smt. Grace Clara Kachhap, wife and nominee of theDLA, stated that LICI authorities repudiated the death claim and her furtherrepresentation was not considered. Briefly facts of the case are as under:Shri Fardinand Toppo purchased a policy on 28.08.01. The proposal was received on28.08.01 and the DOC was 28.08.01. Unfortunately, he died on the very same dayearly in the morning. From the policy papers, it could be seen that he was sufferingfrom jaundice vide report dated 29.08.01. Claim Form ‘B1’ indicateed that he wasbrought dead at 08.30 A.M. to the hospital.A hearing was fixed. The representative of the insurance company attended while thecomplainant did not attend. The representative of the insurance company stated that

the contract was not complete and even if the claim was considered, the patient wassuffering from jaundice before the inception of the policy as per the availablecertification. Under these circumstances, the insurance authorities repudiated theclaim.Decision :On going through the evidence available, it could be seen from the death certificateissued by the Military Hospital at Ranchi that the date of death was 28.08.01. Theclaim form ‘B1’ indicated that the patient was brought dead and the cause of death wasjaundice. The hospital authorities relied on the Post Mortem Report (PMR) dated29.08.01and the report stated that there was no evidence of any injury external orinternal and the death was due to jaundice.On scrutiny of proposal papers, it was found that the DLA deposited Rs. 5,057/- on14.08.01 i.e., 14 days before the date of death and he appeared to have signed theproposal papers on 14.08.01. However, the proposal was received by LICI on 28.08.01(Inward No. 912) and registered under proposal no. 1446 on 29.08.01. Proposal wasunderwritten on 29.08.01. It was a known fact that in the case of First Premium thathas been sent with the proposal and the proposal was accepted without anymodification, the insurer normally assumes risk from the date of acceptance,assumption of risk being communicated by a simple receipt issued for the FirstPremium. However, the acceptance is always subject to the condition that if anyadverse event communicated with the risk has occurred between the date of proposaland the date of acceptance, the assurance will be invalid unless intimation of suchevent is given to the insurer and acceptance is re-approved. In this case, although theproposal deposit was converted into premium and the proposal converted into a policy,the proposer had died before acceptance. Therefore, the contract was not concluded.Under these circumstances, the repudiation of claim by the insurance company wasupheld. However, the premium paid in the form of proposal deposit should be refundedto the legal heir since the contract was not concluded. The insurance company weredirected to refund the amount of premium paid.Kolkata Ombudsman CentreCase No. : 891/24/001/L/03/05-06Smt. Romee SarkarVsLife Insurance Corporation of IndiaAward Dated : 08.03.07Facts & Submissions:This petition was filed by Smt. Romee Sarkar for non-settlement of death claim on thelife of her husband Shri Subhasish Sarkar, deceased life assured (DLA) by LICI.Smt. Romee Sarkar, the complainant, in her original complaint dated 23.03.06 and ‘P’form details received on 12.04.06 stated that her husband Shri Subhasish Sarkar diedon 05.03.05 due to cancer, which was detected on 29.08.03. After his death, shesubmitted the claim forms on 21.09.05 along with all the available papers required bythe insurance company. In spite of her several requests, the insurance company didnot respond and death claim of her deceased husband’s policies remained unsettled.Being aggrieved by non-settlement, this petition was filed seeking relief.The insurance company sent a self-contained note stating that the complainantsubmitted death claim intimation along with forms in respect of the following 4 policiestaken by the DLA:

i) 412787170 (ii) 413363804 (iii) 416013100 (iv) 416013101According to LICI, out of these 4 policies, only policy no. 412787170 was non-earlyclaim under which the mother of the DLA was the nominee. On submission of Probateof the Will dated 30.12.05, the claim in respect of the said policy was paid on 28.01.06to Smt. Romee Sarkar, the complainant. The claim forms for the other 3 policies weresubmitted on 23.12.05. The claimant was asked to submit form no. 5152 after beingcompleted by Dr. P.K.Banerjee but the claimant, according to them, was unable tosubmit the forms. LICI, Zonal Office vide their letter dated 28.02.06 asked forsubmission of the following details:(i) Details of operation (SOL, left Popliteal Fossa) i.e., date, place, name of surgeon,treatment particulars, etc.(ii) Specific observation of Sr.DMThe complainant did not comply with the above requirements. Therefore, a furtherreminder was sent to her on 04.03.06.Initially, the then Ombudsman directed LICI to send a report with regard to the abovecase vide his letter dated 01.08.06. The insurer vide their letter dated 29.12.06 statedthat the death claims under the aforesaid policies stood repudiated by them on24.11.06 on the strength of the evidence of past illness collected by them from ApolloHospital. According to them, discharge summary dated 30.06.03 of Apollo Hospitalindicated that the DLA was suffering from pain and swelling in the left knee for the last20 years and underwent surgical operation in 1997. Before surgery, flexion was 25 to30 degree of mobility and after surgery the same was increased to about 50%. Theystated that this information was not mentioned in the proposal form under question nos.11(a), 11(b), 11(d), 11(e). Therefore, it was held that material information waswithheld, which affected their underwriting decision. LICI, therefore, repudiated theclaim.HEARING :To resolve the issue, a hearing was fixed for 27.02.07 where both the parties attended.The representative of the insurance company gave a copy of the discharge summarydated 30.06.03 from Apollo Hospital, which indicated that the patient was havingcomplaints of pain and swelling in the left knee for the last 20 years. He was operatedin 1997 for one of the knees. The problem recurred in March 2003 and the DLA wasadmitted to Apollo Hospital during the period 19.08.2003 to 30.08.2003. He wasoperated (excision of tumour) on 21.08.03 and Biopsy was done after operation. Thesaid hospital at the time of discharge referred him to Oncologist and advisedchemotherapy on the basis of Biopsy Report.On the other hand, the complainant gave a written submission, which included interaliathe following:(i) The proposal papers were signed blank by her late husband and handed over to theagent in good faith;(ii) The proposal was booked in March’02, whereas her husband underwent surgery inthe year 1997. The period covered was appx. 5 years and, therefore, as per theagent, it had no bearing on the evaluation of the risk on the date of proposal;(iii) The last policy was booked in February’03 and by chance in June’03 ‘FNAC’ of theknee was done at N.G.Medicare and no malignancy was detected;(iv) At the time of proposal, her husband was quite healthy and he was looking after hisbusiness well. She got married in 2000 and was blessed with a daughter in 2001

and, therefore, she interpreted that her husband’s health was in good condition. Inview of the above, she requested that her claim may be considered sympathetically.Decision :The plea of the complainant as signing the proposal form blank without verifying thedetails was not acceptable, as an educated person is required to satisfy himself beforea document is signed by him. If that is so, the answers to the questions should havebeen answered appropriately. The proposal forms for the 3 policies were dated18.03.02, 28.02.03 and 28.02.03 respectively. The DLA was admitted for SynovialSarcoma left knee joint with secondaries chest at Apollo Hospital between 19.08.03 to30.08.03 and discharge summary of that hospital indicated that he underwent anoperation in the year 1997. Such a major operation was not mentioned in the proposalform for the policy taken on 18.03.02 and in the proposal forms submitted for the othertwo policies on 28.02.03. He had not answered correctly to question no. 11(b), which isas under:“Have you ever been admitted to any Hospital or Nursing Home for general check up,observation, treatment or operation?”The complainant’s plea that the operation that was done in 1997 was approximatelybefore 5 years does not have any relevanceThe evidence that has been collected by the insurance authorities was irrefutable inthe sense that the complainant’s husband had not given any detail of his health withregard to knee operation. This was itself a misrepresentation and suppression ofmaterial facts. Therefore, it has to be held that the policy contract between theinsurance company and the insured is vitiated. Under these circumstances, it was heldthat the repudiation of the death claim has been done after proper verification. In fact,the LICI authorities had been just when they paid the death claim for one of thepolicies as it was beyond the limitation of time period fixed. We were, therefore,constrained to state that the petition was dismissed without any relief to thecomplainant.Kolkata Ombudsman CentreCase No. : 385/24/001/L/08/2006-07Smt.Sabitri DeviVsLife Insurance Corpn. of IndiaAward Dated : 09.03.07Facts & Submissions :This petition was filed by the complainant for non-settlement of death claim under apolicy issued by the LICI authorities.The complainant, Smt.Sabitri Devi was the wife and nominee of her late husband,Mahesh Prasad with regard to Policy No.513003171. The DLA died on 16.2.2004. Thecomplainant submitted the Claim Form and the Insurance Company issued the DispatchVoucher for a payable amount of Rs.1,02,718/-. However, the claim remained pending.A hearing was held on 8.3.2007 where only the representative of the InsuranceCompany attended and the complainant did not turn up. The representative of theInsurance Company gave a letter dt.7.3.2007 wherein they stated that a cheque wasissued in favour of the complainant for Rs.99,384/- vide cheque No.130184dt.7.11.2006 which was encashed on 15.11.2006. The cheque included interest fordelay in payment after deduction of the uncollected premium.Decision :

As the insurance company satisfactorily redressed the grievance, no furtherintervention was called for. Hence, the petition was closed and the same was disposedof accordingly.Kolkata Ombudsman CentreCase No. : 436/24/001/L/09/2006-07Sri Krishna JhaVsLife Insurance Corpn. of IndiaAward Dated : 09.03.07Facts & Submissions :The complainant for non-settlement of death claim filed this petition by the LICIauthorities.The complainant, Sri Krishna Jha was the husband and nominee of the policyholder,late Saraswati Devi who expired on 02.04.2004. Sri Krishna Jha filed a death claimunder the said policy to the LICI.As the claim occurred after 1 month and 4 days from the date of commencement of thepolicy, it took some time for the LICI authorities to investigate and come to a decisionwith regard to the admissibility of the claim. In the self-contained note dt.25.2.2007,the Insurance Company stated that they categorically admitted the claim of Rs.35,000/-under Policy No.534390619 and partly repudiated the claim for Rs.15,000/- becausethe DLA being a housewife could not be allowed insurance coverage more than thecoverage on her husband, who had insurance for S.A. of Rs.35,000/- under ‘In Force’Policy No.531781554. The reason for partial repudiation of Rs.15,000/- was that thedeceased furnished wrong information about the status of her husband’s insurancepolicies while submitting proposal on her own life since her husband’s policyno.530929486 for S.A. of Rs.15,000/- was in lapsed condition with F.U.P. 01/2004.Decision :The complainant was requested to submit the required documents immediately, assought for, by the LICI authorities to the concerned Branch for settlement of the claimto the extent of Rs.35,000/-as this had already been considered for payment. As therewas no more grievance to interfere, the petition was closed and the same was disposedof accordingly.Kolkata Ombudsman CentreCase No. : 393/24/001/L/08/2006-0Smt.Puspa KumariVsLife Insurance Corpn. of IndiaAward Dated : 09.03.07Facts & Submissions :This petition was filed by the complainant for non-settlement of death claim under‘Jeevan Anand’ policy issued by the LICI authorities.The complainant, Smt.Puspa Kumari filed a death claim on ‘Jeevan Anand’ policypurchased by her late husband, Chhatu Bhakta with D. O. C. on 28.01.2003. The L/Aexpired on 13.08.2003 due to sudden heart attack. Inspite of filing the claim forms, thesubject claim remained pending.A hearing was held on 8.3.2007, where none of them present. However, InsuranceCompany sent a letter on 6.3.2007 indicating that the claim was settled and paid vide

cheque No.258433 dt.20.2.2007. Probably, only due to that reason the complainant didnot attend the hearing held on 8. 3.2007.Decision :As the Insurance Company satisfactorily redressed the grievance, no furtherintervention was called for. Hence, the petition was closed at our end and the samewas disposed of accordingly.Kolkata Ombudsman CentreCase No. : 213/21/001/L/06/06-07Smt. Bimala JangalwaVsLife Insurance Corporation of IndiaAward Dated : 23.03.07Facts & Submissions:This was a petition filed by the complainant against repudiation of death claim by LICI.Shri Keshri Chand Jangalwa (Soni), deceased life assured (DLA) purchased a LICIpolicy by submitting his proposal on 24.08.2003. He expired on 21.10.2003 atSujangarh, Rajasthan. The duration of the policy was 1 month 23 days. Smt. BimalaJangalwa, wife and nominee of the DLA filed death claim intimation and submitted therequired documents, but the LICI repudiated the claim on the ground of deliberatemisstatement and withholding of material information. The complainant furtherrepresented before the insurance company, which was of no avail. According to her,the DLA had no prior serious illness and the death was due to sudden cardiac failure.She has filed this petition for relief before the Insurance Ombudsman.The insurance company sent a self-contained note. According to them, they haveindisputable proof that the DLA suffered from gastric problem and was under treatmentfrom a Medical Practitioner. LICI, Bikaner Division obtained a certificate from anAyurvedic Practitioner Dr. Ghewar Chand Gujar at Sujangarh that the DLA was underhis treatment for last 4 months prior to death. According to them, the DLA suppressedthese facts at the time of proposal. Had the DLA disclosed the above information priorto taking the policy, the underwriting decision would have been otherwise. LICI,therefore, contended that there was misrepresentation and deliberate misstatementand hence, the repudiation decision was in order.HEARING :A hearing was fixed wherein only the representative of the insurance companyappeared. The complainant did not appear nor did she send any request foradjournment. However, a hearing was fixed once again for 20.03.07 requesting thepetitioner to attend. The complainant attended with her relative. The complainant wasinformed that the policy was taken on 24.08.03 and the DLA expired on 21.10.03.Therefore, the insurance company made enquiries due to early claim. In thoseenquiries, it has been found that the DLA was suffering from gastric problem since 4-5months as per the certificate issued by Dr. Ghewar Chand Gujar, Ayurvedic Doctor.Apart from that they have also made enquiries from the neighbour, who gave in writingthat the DLA was suffering from gastric problem and was attended to by the abovedoctor. The statements were read out and she could understand the contents of thesame. The relative was also informed that due to the certificate given by the Doctorthat he was suffering from gastric problem since 4-5 months, the period falls before theinception of the policy and, therefore, the proposal form should have contained theinformation with regard to ailment the DLA was suffering. Since the proposal form does

not mention any of the problems, the insurance company repudiated the claim on theground that there was suppression of material facts.Decision :As it was an early claim (1 month 23 days) and there is proof that the DLA wassuffering from gastric problems, it could not be stated that the DLA was not in theknowledge of his ailment at the time of signing the proposal form. Therefore, it had tobe held that there was suppression of material facts. Under these circumstances, I donot have any other alternative but to agree with the decision of repudiation made byLICI. Accordingly, no relief was granted to the complainant.Kolkata Ombudsman CentreCase No. : 268/24/001/L/07/2005-2006Shri Tapan Kumar LahiriVsLife Insurance Corporation of IndiaAward Dated : 28.03.07Facts & Submissions :The Insurance Ombudsman vide his order dated 18.11.2005 had passedrecommendation as under:“We have considered the facts and circumstances of the case as well as the materialsavailable on record. In the instant case the policyholder expired after the date ofmaturity of the claims. The registered nominee pre-deceased the life assured. Thecomplainant is one of the legal heirs of the said claim. The insurer expressed theirinability to settle the claim due to non-submission of the original policy bond and lastpremium receipt. Submission of the policy bond in original and last premium receipt arerequired for the creation of the master and claim proceeds. Only on receipt of thepolicy bond in original, the servicing Branch can proceed in the above matter. We,therefore, direct the complainant to submit the required documents to LICI forsettlement of the claim. LICI will also process quickly and decide the claim afternecessary verification with their record. LICI will decide the claim within a month fromthe date of receipt of the required particulars asked for by them.”The claimant wrote a letter dated 26.07.06 stating that the LICI has not given effect tothe aforesaid order even after he had sent the policy bonds and informed that he wasunable to produce premium receipts. Keeping in view the difficulties expressed by thecomplainant and the insurance authorities, a hearing was fixed for 20.03.07 where boththe parties attended. The claimant stated that the policies were very old. Policy no.9252197 with DOC 23.09.1959 with Sum Assured of Rs. 1000/- was having a monthlypremium of Rs. 6.23 and matured in 1974. Policy No. 9448492 with DOC 15.09.1961with Sum Assured Rs. 2500/-; monthly premium of Rs. 15.69 and matured in 1976.Similarly, policy no. 9459223 with DOC 01.11.1961; quarterly premium of Rs. 47.50and matured in 1976. The complainant stated that the policies had been assigned andreassigned during that period and premium was deducted from the salary of his fatherand, therefore, he was unable to send the last premium receipt. However, he sent theoriginal policy bond to the company.The representative of the insurance company stated that the claim was very old andthey were not able to lay their hands on old records like policy records, ledger folio orclaim papers. According to them, when the policy is matured, the claim operations werecentralized under the then Calcutta Division.

We were unable to modify the order made by the previous Ombudsman. It is suffice tosay that the policy bonds that have been submitted with the information assignmentand reassignment and the fact that premiums were deducted from salary would indicateall premiums have been paid and question of verification, whether the premiums werepaid, now is not possible due to efflux of time. Under these circumstances, theinsurance company is requested to take a decision with regard to the payability of thesum assured to the claimant after taking the above facts into consideration.However, the claimant is at liberty to seek redressal of his grievance with any otherforum including this forum if the decision by the insurance company is not acceptableto him.Kolkata Ombudsman CentreCase No. : 562/21/001/L/11/06-07Shri Sushil GuptaVsLife Insurance Corporation of IndiaAward Dated : 28.03.07Facts & Submissions :This petition was filed by the complainant Shri Sushil Gupta for repudiation of deathclaim on the life of his father Shri Puttu Lal Gupta, deceased life assured (DLA) byLICI.Shri Sushil Gupta, son and nominee of the DLA Late Puttu Lal Gupta, stated that hisfather had taken a policy with DOC 28.03.1999. The life assured died on 15.12.2001.After the death, a claim was raised against the policy and the same was repudiated onthe ground of non-disclosure and suppression of material facts. The representationmade by the complainant did not yield any result. Therefore, this petition has been filedfor relief.The insurance company stated that the policy was allowed to be lapsed by the lifeassured for non-payment of premium due on 28.06.1999 without acquiring any paid upvalue. The policy was revived on 02.07.2001 for full sum assured on the strength ofpersonal statement regarding health made by the deceased on 27.06.2001. The lifeassured had answered question no. 2(a) as “No” and question no. 4 as “Good” in therevival form. The insurance company maintained that they have indisputable proof toshow that the DLA had been suffering from Chronic Obstructive Pulmonary Diseaseand that he had suffered from Pulmonary Tuberculosis with Pulmonary Fibrosis, but hedid not disclose these facts in the personal statement. The policy was revived on02.07.2001 and the life assured died on 15.12.2001 at Marwari Relief Society Hospital,Kolkata. The duration of the policy after revival was only 5 ½ months and the hospitalrecords indicated that the life assured was a known case of COPD with old PulmonaryKoch. These diseases were chronic in nature. Therefore, the insurance company heldthat that there was suppression of material facts in the revival form and repudiated theclaim.A hearing was fixed wherein both the parties attended. The complainant was informedthat though the policy was taken originally w.e.f. 28.03.1999, it got lapsed due to nonpaymentof premium due on 28.06.1999. The policy that was taken up for revival on02.07.2001 would be treated as a fresh policy and any disease prior to this date had tobe mentioned in the personal statement form. He was also informed that theDeclaration of General Health signed by the DLA did not contain any informationregarding his disease because of which the life assured passed away. The

epresentative of the insurance company defended the decision of repudiation of claimon the lines mentioned above i.e., non-disclosure of material fact in the proposal form.Decision :The complainant was informed that the revived policy was only 5 ½ months old and thatthe DLA was suffering from chronic diseases which was within his knowledge whilesigning the personal statement form and, therefore, it could be easily inferred that hehad not disclosed the health condition in the personal statement even after having theknowledge of the same. It was, therefore, held that there was suppression of materialfacts at the time of reviving the policy. Under these circumstances, we did not have anyother alternative but to agree with the decision of the insurance company with regard torepudiation of the claim. The petition was dismissed without any relief to thecomplainant.Kolkata Ombudsman CentreCase No. : 172/24/001/L/06/06-07Shri Prabir Kumar BoseVsLife Insurance Corporation of IndiaAward Dated : 30.03.07Facts & Submissions :This petition was filed by the complainant Shri Prabir Kumar Bose for non-settlement ofclaim arising out of death of his father Late Jiban Krishna Bose, deceased life assured(DLA).The complainant was the nominee under policy no. 430937612 with DOC 07.02.1993.The life assured died on 27.02.1994, 1 year 20 days after the commencement of thepolicy. The complainant submitted the claim forms on 25.01.2005. As the claimremained pending, this petition has been filed before this forum for relief.LICI stated that the life assured died of Cirrhosis of Liver at home after 1 year 20 daysof taking the policy and the nominee sent the claim forms on 18.01.2005, nearly 11years after death, date of death being 27.02.1994. There was no possibility of anyinvestigation to be conducted to determine the allowability of the claim.HEARING :Originally a hearing was fixed for 06.02.2007. The Petitioner did not attend but sent arepresentative who was not permitted to attend. Therefore, another hearing was fixedfor 20.03.07 where both the Petitioner and the representatives of the insurancecompany attended. The Petitioner was asked why the claim was made after 11 yearswhen the life assured died on 27.02.1994. According to him, he sent a letter on03.09.1996 informing the death of his father. In response to this letter, the insuranceauthorities requested him to submit all the documents including the death certificate,etc. vide their letter dated 05.09.1996. He, however, stated that this letter was repliedonly on 27.09.2004 i.e., nearly 8 years later. He was asked why there was a delay insubmitting these forms for 8 years. He stated that obtaining the death certificate tooklot of time and the same was issued to him only on 11.09.2004. He could not give anyreason for such inordinate delay.The representatives of the insurance company defended their repudiation decision onthe ground that the claim was made after more than 10 years and that the medical

certificates submitted by the claimant contained the cause of death as “Cirrhosis ofLiver”. Therefore, according to them, the repudiation was done correctly.DECISION :On going through the evidence available, I am unable to agree with the complainantthat the death certificate could not be obtained earlier. The delay was about 8 years.Therefore, verification of claim makes it impossible for any insurance company. Addedto this, the claim forms filed by the insured indicate cause of death as “Cirrhosis ofLiver” and that the death occurred within 1 year 20 days after the DOC indicates that“Cirrhosis of Liver” existed prior to the inception of the policy. There was undue delayin submission of the claim papers and therefore, verification and investigation of claim,since the death of the life assured was within one year twenty days from the date of thepolicy cover, was very difficult. Therefore, under these circumstances, we had to agreewith the repudiation made by the LICI and reject the petition without any relief to thecomplainant.Lucknow Ombudsman CentreCase No. : L-326/21/001/06-07Smt.Veena DeviVsLife Insurance Corporation of IndiaAward dated 30.10.2006Smt. Veena Devi had lodged a complaint with Insurance Ombudsman for allegedlyunjustified repudiation of claim by LIC of India under policy no.562381325 on the life ofher husband Shri Sukhveer Singh. The claim was denied on the ground of suppressionof material fact relating to the illness of Peri ampullary Carcinoma with which thedeceased life assured was suffering prior to the date of proposal which wasestablished from the certificate of employer submitted by the insurer. The proposal inthe case though was not submitted but in the facts & circumstances of the case whenthe deceased life assured could not have been granted insurance if he would havedisclosed the details of illness of Peri ampullary Carcinoma with which he was sufferingfrom, obvious inference was that he had not disclosed the same in the proposal form.Although technically it was a lacunae in the evidence led by the insurer but since theInsurance Ombudsman is not bound by all the technical rules of evidence but underRPG rules 1998 is only required to dispose of a complaint fairly and equitably, therepudiation in the facts and circumstances was held to be in order.Award dated 30.10.2006Lucknow Ombudsman CentreCase No. : L-431/21/001/06-07Shri Amitesh MakanVsLife Insurance Corporation of IndiaShri Amitesh Makan had lodged a complaint with Insurance Ombudsman for allegedlyunjustified repudiation of claim by LIC of India under policy no.263254593 on the life ofhis mother Smt. Latika Makan on the ground that there was material nondisclosureabout her health, and having pain in her abdomen, in the proposal form for the last 2years. The fact of nondisclosure was established by the insurer by submission ofcertificate of hospital treatment from Krishna Kare Hospital, Agra. Although thecomplainant stated that the duration of her disease suffering from pain on right side of

the abdomen for last 2 years was stated by her to the doctor which was incorrect butno reasons were ascribed nor this was supported by the discharge summary of thehospital. The repudiation of the claim therefore on the ground of nondisclosure ofmaterial was held to be in order.Lucknow Ombudsman CentreCase No. : L-405/21/001/06-07Shri Nidhish Kumar GuptaVsLife Insurance Corporation of IndiaAward dated 30.10.2006Shri Nidhish Kumar Gupta had lodged a complaint with Insurance Ombudsman forallegedly unjustified repudiation of claim by LIC of India under policy no.271221053under Jeevan Sathi policy. The claim was repudiated on the ground that there wasmaterial nondisclosure about the ailment of breast cancer with which the life assuredSmt. Taruna Gupta was suffering from for last 3 months. Besides although she hadconsulted the doctors as an OPD patient at Himalayan Institute Hospital, Dehradunafter submitting the proposal but before it was accepted she had failed to intimate thestate of her health after knowing that she was suffering from cancer. The insurersubmitted the copy of OPD card and discharge summary from Himalayan InstituteHospital, Dehradun. On a perusal of the certificates it was established that thedeceased life assured had consulted first the doctors of the hospital authorities as OPDpatient on 24.05.03. Since the history stated by her was to the effect that she washaving the problem of breast cancer for last 3 months, it was obvious that she hadfailed to discharge the obligation of intimation of the state of health before acceptanceof the proposal which was a breach of warranty as contained in the proposal form. Therepudiation of the claim was, therefore, held to be in order.Lucknow Ombudsman CentreCase No. : L-411/21/001/06-07Smt. Maduri DeviVs.Life Insurance Corporation of IndiaAward dated 09.11.2006Smt. Maduri Devi had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy no.311300555 on the life ofher husband Shri Mewa Lal on the ground that the life assured four years back prior tothe date of proposal was suffering from diabetes mellitus and had consulted doctors forthe purpose. The insurer in support of its contention submitted the copy of BHT fromSGPGI, Lucknow and the copy of certificate of Hospital treatment from SGPGI,Lucknow based on the evidence submitted the repudiation of the claim was held to bein order.Lucknow Ombudsman CentreCase No. : L-379/21/001/06-07Smt. PhoolpattiVsLife Insurance Corporation of IndiaAward dated 09.11.2006

Smt. Phoolpatti had lodged a complaint with Insurance Ombudsman for allegedlyunjustified repudiation of claim by LIC of India under policy no.283418294 on the life ofher husband Shri Ram Kumar Pandey on the ground that the life assured was sufferingfrom cancer and fistula in ano and was also a smoker and addicted to chewing Khaini.The insurer submitted the copy of BHT from SSS hospital, BHU Varanasi wherein itwas clearly stated that the deceased was a follow up case of BronchoalveolarCarcinoma cancer with Fistula in ano. Since the death of the life assured had takenplace within less then 4 months of taking the insurance, as per BHT it was a follow-upcase and in the opinion of the DMR the Bronchoalveolar Carcinoma takes minimum oneyear to cause death, it was established that the deceased life assured had suppressedmaterial facts regarding his illness with which he was suffering prior to the date ofproposal and hence the repudiation action taken by the insurer was held to be in order.Lucknow Ombudsman CentreCase No. : L-429/21/001/06-07Smt. Manju ChaturvediVsLife Insurance Corporation of IndiaAward dated 13.11.2006Smt. Manju Chaturvedi had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy no.214695948 on the life ofher husband Shri Sanjay Chaturvedi on the ground that in the proposal dated 11.02.05he had not disclosed about the illness of Myocardial Infarction With which he hadsuffered in the past and had also undergone Coronary Angiography and had remainedadmitted in the hospital. The insurer having established the above nondisclosure ofmaterial facts by submitting a copy of BHT and certificate of Hospital treatment andcertificate of medical attendant from SGPGI, Lucknow, the nondisclosure being withintwo years from the date of effecting the insurance, the repudiation of claim underpolicy no.214695948 was held to be in order.Lucknow Ombudsman CentreCase No. : L-297/21/001/06-07Shri Anupam Kumar DubeyVsLife Insurance Corporation of IndiaAward dated 14.11.2006Shri Anupam Kumar Dubey had lodged a complaint with Insurance Ombudsman forallegedly unjustified repudiation of claim by LIC of India under policy nos.283653924 &284675668 on the life of his father Shri Sudama Dubey on the ground that he wassuffering from diabetes and kidney diseases prior to the date of the proposal. Theinsurer, however, did not submit any evidence in support of its decision except theinvestigation report of the two officers who had also not collected any evidence insupport of their findings. Since no evidence was submitted by the insurer, therepudiation of the claim by the insurer was set aside and the claimant awarded fullpayment of claim amount under both the policies by the insurer.Lucknow Ombudsman CentreCase No. : L-344/21/001/06-07Smt. Shahida BegumVs

Life Insurance Corporation of IndiaAward dated 14.11.2006Smt. Shahida Begum had lodged a complaint with Insurance Ombudsman for allegedlyunjustified repudiation of claim by LIC of India under policy no.270290714 on the life ofher husband Shri Shamshad Ahmed on the ground that on the date of the revival andthe date of personal statement regarding health the deceased life assured was takingtreatment in Prankur Hospital & Research Centre, Saharanpur which fact was notdisclosed in the personal statement regarding health. This was established by theinsurer by submitting certificate of hospital treatment from the Hospital authority whichstated that the deceased life assured was admitted in the hospital on 12.02.05 anddischarged on 17.02.05. The decision of the insurer therefore by admitting only paid upvalue under the policy was held to be in order.Lucknow Ombudsman CentreCase No. : L-379/21/001/06-07Smt.Shanti DeviVsLife Insurance Corporation of IndiaAward dated 14.11.2006Smt. Shanti Devi had lodged a complaint with Insurance Ombudsman for allegedlyunjustified repudiation of claim by LIC of India under policy no.292250713 on the life ofher husband Shri Rajkumar Jaiswal on the ground that there was nondisclosure ofearlier policy no.291259118 which was lying in lapsed condition since September, 1999and was not disclosed in the proposal form dated 12.09.02 submitted under impugnedpolicy. The insurer submitted copy of computer generated status report in support of itscontention but the complainant insisted upon that a cheque in payment of quarterlypremium due 09/99 under policy no.291259118 had been dishonoured and as such thepolicy was lying in lapsed condition since June 1999 and not September 1999 and theperiod of lapsation was therefore more than 3 years. The insurer having further verifiedits cash books has now confirmed the contention of the complainant and as such theletter of repudiation dated 30.03.05 under impugned policy was set aside and fullpayment of claim alongwith accrued bonus was awarded to the complainant.Lucknow Ombudsman CentreCase No. : L-53/21/001/06-07Shri Sohan Lal VermaVsLife Insurance Corporation of IndiaAward dated 15.11.2006Shri Sohan Lal Verma had lodged a complaint with Insurance Ombudsman for allegedlyunjustified repudiation of claim by LIC of India under policy no.270845360 on the life ofSmt. Chandrawati on the ground that in the proposal form and self declaration she hadunderstated her age by about 24 years and that she was, therefore, uninsurable at thetime the policy was effected. The insurer submitted the copy of will dated 18.11.1991,carrying a photo of the assured on the face of the document where under the assuredhad declared herself to be 65 years of age approximately, in support of its repudiationof claim. As per this document the life assured was 65 years of age on the date ofexecution and 74 years of age as on the date of the proposal. The complainant did not

dispute the will but contended that the life assured was an illiterate lady suffering froma stammer in her speech and that the compiler might have recorded a different agethan actually stated by her. However, this argument on the face of it was not tenable asthe document carried the photograph of the lady also and the lady as per thephotograph affixed on the deed appeared to be of the age as declared in the document.The repudiation of the claim was, therefore, held to be in order.Lucknow Ombudsman CentreCase No. : L-316/21/001/06-07Smt. Ram BetiVsLife Insurance Corporation of IndiaAward dated 20.11.2006Smt. Ram Beti had lodged a complaint with Insurance Ombudsman for allegedlyunjustified repudiation of claim by LIC of India under policy no.221463648 on the life ofher husband Shri Reet Ram on the ground that the life assured was suffering fromCOPD disease prior to the date of the proposal under the policy and he had notdisclosed the same in the proposal. In support of its decision, the insurer submitted thefamily medical treatment card of OCF Hospital, Shahjahanpur, copy of medicalattendant certificate/copy of certificate of hospital treatment from OCF hospital,Shahajahanpur, certificate of leave on claim form ‘E’ from the employer of the decease.As per the family treatment card of OCF hospital, Shahajahanpur Shri Reet Ram, Lifeassured had consulted the doctor at the hospital prior to the date of proposal and wasdiagnosed as suffering from dysponea. As per the certificate of Hospital treatment thedeceased was an old case of COPD. These facts were not disclosed in the proposalform. The insurer thus having established that the deceased life assured was sufferingfrom the disease prior to the date of the proposal about which he had the knowledgeand had not disclosed the same in the proposal form, the repudiation of the claim washeld to be in order.Lucknow Ombudsman CentreCase No. : L-362/21/001/06-07Smt.Saraswati DeviVsLife Insurance Corporation of IndiaAward dated 23.11.2006Smt. Saraswati Devi had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy no.283866385 on the life ofher husband Shri Ram Narayan Maurya on the ground that prior to the date of proposalhe was not in a good health; was a disabled person and was coming to the school in atricycle which facts were not disclosed by him in the proposal form. If these facts werecorrectly disclosed he would not have been given policy under Plan 149 at this age. Insupport of its contentions the insurer submitted statements from one Shri KrishnaMohan Maurya and Tej Nath Chouhan residents of the same village and Shri BechuSingh, Head Master, Purva Madhyamik Vidyalaya where the life assured was doing theteaching job. The complainant contested these allegations and stated that her husbandwas in a good health before the date of proposal and was not a disabled person.Besides he was medically examined also by Corporation’s doctor before the proposalwas accepted. In her support she submitted statements from Gram Pradhan of thevillage where the life assured was residing as also from Gram Pradhan of the villagewhere he was doing the teaching job and also one Shri Bhrigunath Ram who was the

life assured’s colleague in the school. In all these statements it was clearly stated thatthe life assured was in sound health before the date of proposal and was not adisabled person. Considering the contradictory statements from the residents of villagewhere the life assured was residing / teaching, the Insurer’s representative was askedto submit affidavits from Shri Bechu Singh, Shri Tej Nath Chouhan and Shri KrishnaMohan Maurya as also any documentary evidence in support of the Insurer’s contentionsuch as prescriptions cash memo of medicines and hospital record of treatment etc.The complainant was also asked to submit her own affidavit and also affidavit fromGram pradhan of the village where the life assured was residing as well as also fromthe Gram Pradhan of the village where he was teaching; from Shri Bringunath Ram andalso from an independent neighbour Shri Katwaru Maurya (Retired Sainik). Both theparties were allowed 15 days time for submitting the affidavits. Whereas thecomplainant has submitted all the evidences as directed the insurer has failed tosubmit any affidavit. Instead its two witnesses Shri Tej Nath Chouhan and KrishnaMohan Maurya have sent their affidavits directly retracing back from their earlystatement given before the investigating Officer. It was, therefore, obvious that theinsurer has no documents to fall back in support of its repudiation and as suchrepudiation was held to be bad in law and the repudiation letter was set aside awardingfull payment of claim alongwith the bonuses as per policy conditions.Lucknow Ombudsman CentreCase No. : L-485/21/001/06-07Shri Ashok Kumar AgarwalVsLife Insurance Corporation of IndiaAward dated 30.11.2006Shri Ashok Kumar Agarwal had lodged a complaint with Insurance Ombudsman foralleged unjustified repudiation of claim by LIC of India under policy no.263145055 onthe life of his mother Smt. Dinesh Agarwal on the ground that there was misstatementof facts regarding the age of her youngest child and that earlier policy no.261846374was not disclosed in the proposal form. If these facts were disclosed the insurancecould not have been granted to her since she was a widow. However, no evidenceincluding the copy of the proposal which is the basis of contract and in which abovemisstatements were stated to have been made was produced as evidence to establishthe contentions of the insurer. In absence thereof, the repudiation was held to be badin law and not satisfying the conditions under Section 45 of Insurance Act 1938. Fullpayment of claim amount alongwith accrued bonus was, therefore, awarded tocomplainant nominee.Lucknow Ombudsman CentreCase No. : L-308/21/001/06-07Smt. Durga DeviVsLife Insurance Corporation of IndiaAward dated 30.11.2006Smt. Durga Devi had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy no.282692529 on the life ofher husband Shri Ram Sewak Prasad Pal on the ground that the personal statementregarding health dated 22.01.03 submitted by the life assured for revival of policy on23.01.03 was not actually signed by him but by some one else. In order to substantiateits contention the insurer submitted the hand writing expert’s opinion of M/s R.K.

Jaiswal who in their report confirmed that the disputed signature marked as D-1 on theDGH dated 22.01.03 was not written by the writer of the admitted signature marked asA-1 on the proposal dated 28.12.01. The complainant did not submit any evidence tocontradict the contention of the insurer. Since the contracts of insurance are contractsof utmost good faith and a fraud was perpetrated in getting the policy no.282692529 onthe life of late Shri Ram Sewak Prasad Pal revived on 23.01.03, the repudiation of theclaim by the insurer was held to be in order.Lucknow Ombudsman CentreCase No. : L-136/21/001/06-07Smt. Nirmala DeviVsLife Insurance Corporation of IndiaAward dated 30.11.2006Smt. Nirmala Devi had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy nos.283727653 and283729391 on the life of her husband Shri Chhedi Lal Gupta on the ground that therewas suppression of material facts regarding his illness of UGI bleed etc. with which hewas suffering prior to the date of proposal. No evidence was, however, produced by theinsurer and its decision was based on the opinion of insurer’s Divisional MedicalReferee who had opined that the illnesses relating to the assured mentioned incertificate of treatment at Hospital and certificate of medical attendant could havedeveloped over a minimum of 3 – 5 years. No corroborative evidence to support thefindings of DMR was produced nor it was established that even if the deceased lifeassured was suffering from these illnesses 3 – 5 years prior to the date of proposal thiswas within his knowledge. As per Section 45 of Insurance Act 1938 even if claim isrepudiated within two years from the date policy was effected the insurer is required toestablish that the information suppressed by the deceased life assured was on materialfacts and that these were within his knowledge. Having not been able to establishthese ingredients, the letter of repudiation dated 26.05.05 issued by the insurer wasset aside and full payment of claim under both the policies alongwith the accruedbonus was awarded to the complainant nominee.Lucknow Ombudsman CentreCase No. : L-435/21/001/06-07Shri Sanjay Kumar JainVs.Life Insurance Corporation of IndiaAward dated 30.11.2006Shri Sanjay Kumar Jain had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy no.263384825 on the life ofhis wife Smt. Shobha Jain on the ground that the life assured had not disclosedmaterial facts regarding her illness with which she was suffering prior to the date ofproposal and had fraudulently in connivance with the Agent avoided medicalexamination by making an impostor to appear before the LIC medical examiner. Insupport of its contention the insurer’s representative submitted the prescriptions of Dr.N.L. Patney, BHT from Ram Raghu Hospital, Agra, copies of proposal form dated28.03.04 and medical report dated 28.03.04 alongwith Hand-writing Expert Shri DeepakKashyap’s report dated 05.04.06 and the opinion of its DMR Dr. Rajeev Mangal.

Although the BHT and the prescriptions could only establish that the deceased lifeassured was suffering from CRF since Jan., 05 but from the proposal and the medicalexaminer’s report dated 28.03.04 it was obvious that the life assured who had signedthe proposal form had not signed the medical examiners report leading to theconclusion that the life assured was not produced for medical examination and someimposter was produced by the Agent for avoiding the correct medical examination anddiagnosed of the disease with which the life assured was suffering from. Thus a fraudwas practiced on the Corporation by the life assured in connivance with the agentwhich was established from the hand-writing Expert’s opinion. Since no one can beallowed to reap benefits out of his/her fraud the repudiation action in repudiating theclaim under policy 263348825 was upheld.Lucknow Ombudsman CentreCase No. : L-317/21/001/06-07Smt. Marro DeviVsLife Insurance Corporation of IndiaAward dated 08.12.2006Smt. Marro Devi had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy no.221684371 on the life ofher husband Late Shri Jaswant on the ground of gross understatement of age in theproposal form. The Insurer had submitted copy of Pariwar Register, copy of RationCard carrying the photograph of the late life assured and copy of a will dated 04.04.02also carrying the photograph of late life assured. The claimant has disputed thePariwar Register but has not commented any thing about Ration Card and the copy ofwill dated 04.04.02 and has also not submitted any other document to establish thecorrect age of the late life assured. I have, therefore, concluded that the twodocuments viz. copy of Ration Card and Copy of will dated 04.04.02 carrying thephotograph of late life assured inspire more liability and as such the life assured hadgrossly understated his age by more than 12 years in the proposal form. The claimhad, therefore, rightly been repudiated by the insurer. However, the award will notcome in the way of payment of refund of premiums offered by the Zonal Manager to thecomplainant on ex-gratia basis.Lucknow Ombudsman CentreCase No. : L-337/21/001/06-07Shri Ranjan AgarwalVsLife Insurance Corporation of IndiaAward dated 15.12.2006Shri Ranjan Agarwal had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy no.283192475 on the life ofhis father Shri Bharat Das Agarwal on the ground that he was suffering from Chronicrenal disease prior to the acceptance of the proposal under the policy. The insurer inits support submitted the copy of the certificate from one Dr. S.B. Singh which statedthat the deceased life assured was suffering from chronic renal failure and furtherstated that it was submitted by the complainant himself along with an affidavit to theinvestigating Officer. Although the complainant stated that it was a fake certificate andsubmitted an affidavit from the Doctor that he had not issued any such certificate or

treated the person but since the signatures of the doctor on the affidavit did not tallywith his signature on the certificate and that original of the affidavit was not producedand also that it was submitted by the complainant himself, the certificate submitted byinsurer appeared to be reliable and complainant’s version are after thought, therepudiation of the claim, therefore, was held to be in order.Lucknow Ombudsman CentreCase No. : L-451/21/001/06-07Smt. Sarojini SainiVsLife Insurance Corporation of IndiaAward dated 15.12.2006Smt. Sarojini Saini had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy no.232261766 on the life ofher Husband Shri Jagdish Chandra Saini on the ground that there was non-disclosureof the old T & D Kock’s infection in lungs with which deceased life assured wassuffering prior to revival of policy. The policy was lying in lapsed condition since11/2003 and was revived on 14.06.05 on payment of premium due 11/2003 and11/2004 on the basis of personal statement regarding health dated 19.04.05. Theinsurer in its support submitted copy of prescription dated 11.08.05 from one Dr. A.N.Chaturvedi which stated that the deceased life assured had consulted him for acuteBronchitis and CHF and was suffering from old T & D Kock’s infection in lungs on11.08.05. The pathological reports also suggested that he had a high creatinine value.Although the insurer could not submit any document establishing ailments of thedeceased life assured prior to the date of revival but since he had died within 2 monthsfrom the date of revival and that just after two months from the date of revival he hadconsulted Dr. A.N. Chaturvedi for serious ailments it was suggestive that he wassuffering from these ailments prior to the date of revival and that he had knowledge ofthe same and that he did not disclose the ailments in the Personal statement regardingworth to gain unfair advantage. The repudiation of claim and offer of paid up value tothe complainant was, therefore, held to be in order.Lucknow Ombudsman CentreCase No. : L-380/21/001/06-07Shri Ram PrasadVs.Life Insurance Corporation of IndiaAward dated 19.12.2006Shri Ram Prasad had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy no.214488494 on the life ofhis wife Smt. Dayawati on the ground that there was suppression of material factrelating to the disease of bleeding piles with which she was suffering from prior to thedate of the proposal. The insurer in his contention submitted the copy of a certificate ofHospital treatment from District Hospital where at the time of admission the lifeassured herself had stated the history of the disease to be for last 3 years. Since thisperiod ranged prior to the date of proposal and that no evidence to contradict this wassubmitted by the complainant, the repudiation of the claim by the insurer was held tobe in order.Lucknow Ombudsman CentreCase No. : L-593/21/001/06-07

Smt. Kusum Lata SrivastavaVsLife Insurance Corporation of IndiaAward dated 22.12.2006Smt. Kusum Lata Srivastava had lodged a complaint with Insurance Ombudsman foralleged unjustified repudiation of claim by LIC of India under policy no.310923320 onthe life of her husband Shri Alakh Nath Srivastava on the ground that he hadwithheld/suppressed material information regarding the disease of diabetes with whichhe was suffering from last 13 years and disease of hypertension with which he wassuffering from last 3 years. The insurer in support of its contention submitted the copyof certificate of last medical attendant from KG Medical College, Lucknow (claim form‘B’) and certificate of hospital treatment (claim form ‘B1’) from KG Medical college,Lucknow. As per these certificates the deceased life assured was admitted in thehospital on 13.03.02 and died on 14.03.02. The patient was a known case of diabetesmellitus with which he was suffering from last 13 years and hypertension with which hewas suffering from for last 3 years. The history was narrated by relative as the patientwas unconscious. This fact was further corroborated by the complainant’s ownadmission in her representation to the Zonal Manager and by the complainant’srepresentative during personal hearing. However, she stated that this was brought tothe knowledge of the concerned agent by her husband and that her husband wascompletely hale and hearty performing his normal duties.Since the fact that the life assured was suffering from diabetes and hypertension hasbeen established by the evidences submitted by the insurer and also by thecomplainant own admission it was immaterial that the deceased life assured hadbrought this fact to the knowledge of the agent who had filled in the proposal form as itis well established that the agent while filling in the proposal form represents the lifeassured and not the insurer. Further the life assured has signed the declarationwherein he had declared that he is signing the proposal form and the questioncontained therein after fully understanding the same and that these were correct andcomplete in all respect and that nothing was withheld. Looking to the above therepudiation of the claim by the insurer was held to be in order.Lucknow Ombudsman CentreCase No. : L-272/21/001/06-07Shri Shree Pal SinghVsLife Insurance Corporation of IndiaAward dated 22.12.2006Shri Shree Pal Singh had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy no.221577679 on the life ofhis Uncle Shri Pahalwan Singh on the ground of understatement of age in the proposalform dated 07.05.2000. The insurer relied on the copy of Pariwar register but thecomplainant produced another Pariwar register and the Ration Card as per which therewas no understatement of age. Besides he also produced the original of these twodocuments and the affidavit in support of the age of the life assured from the presentGram Panchayat Vikas Adhikari and the Gram Pradhan, whereas the insurer’srepresentative failed to produce the original of the Pariwar register or an affidavit fromthe Ex or the present Gram Panchayat Vikas Adhikari stating any understatement ofage by the life assured. The repudiation was, therefore, held to be not sustainable inthe absence of any evidence and as such the letter of repudiation dated

31.03.05/11.04.05 issued under the policy was set aside and the complainant wasawarded his share of the claim amount under the policy as per rules of the insurer.Lucknow Ombudsman CentreCase No. : L-408/21/001/06-07Smt. Anita MishraVsLife Insurance Corporation of IndiaAward dated 29.12.2006Smt. Anita Mishra had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy no.231238050 on the life ofher husband Shri Sohan Lal Mishra on the ground of material suppression of factsregarding his illness of Gasteroenteritics prior to the date of proposal. The insurer’srepresentative submitted copy of prescription of Dr. A.K. Omar dated 27.11.02, receiptof pathological reports from Parakh Diagnostic Centre dated 28.11.02, receipt ofmedicines dated 28.11.02 and medical certificate of Dr. A.K. Omar for availing leave onmedical ground between 27.11.02 to 29.11.02. It was the insurer’s contention thatdeceased life assured had suffered from illness of Gasteroenteritics from 27.11.02 andthat he was under continous treatment since then till his death. No evidence was,however, adduced in support of its contention except the above. The complainantdenied the above allegations and submitted even the copy of the pathological report ofParakh Diagnostic Centre. On perusal of the pathological reports it was observed thatthe deceased life assured was suffering from low haemoglobin and high SGPT on28.11.02. Further on the basis of pathological reports taken few days before his death,low haemoglobin and high SGPT were observed as persisting. Looking to the above,the repudiation of the claim by the insurer was held to be in order. However, to be justand fair to the complainant, the payment of basic sum assured was awarded as exgratia.Lucknow Ombudsman CentreCase No. : L-387/21/001/06-07Shri Raj Kumar VermaVsLife Insurance Corporation of IndiaAward dated 09.01.2007Shri Raj Kumar Verma had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy no.283804474 on the life ofhis mother Smt. Suhuti Devi on the ground that the life assured had misstated heroccupation as vegetable vendor in the proposal form whereas she was a house holdlady only and could not have been granted insurance without having an equivalentpolicy on the life of her husband. In support of its contention the insurer submittedstatements from her husband and father-in-law signed on a plain paper. Thecomplainant nominee, the son of the life assured on the other hand disputed theallegations as well as the statements submitted by the insurer and submitted anaffidavit from Gram Pradhan and statement from two residents from the locality to theeffect that her mother, the late life assured was engaged in growing and sellingvegetables. The insurer was given 30 days time to submit an affidavit from the husbandand father-in-law of the life assured who had given statement on plain paper but theinsurer failed to submit that within the stipulated time. Since these statements given onplain paper have got no evidentiary value, the repudiation of the claim by the insurer

on the basis thereof was set aside and the complainant nominee awarded the full sumassured along with accrued bonus.Lucknow Ombudsman CentreCase No. : L-552/21/001/06-07Shri Madhav Prasad SrivastavaVsLife Insurance Corporation of IndiaAward dated 15.01.2007Shri Madhav Prasad Srivastava had lodged a complaint with Insurance Ombudsman foralleged unjustified repudiation of claim by LIC of India under policy no.214377059 onthe life of his son Shri Sandeep Kumar Srivastava on the ground of nondisclosure ofillness of bronchial Adenoma with which he was suffering for last 6 months. The Insurerin its support submitted copies of certificate of medical attendant and certificate ofhospital treatment from Sir Sundar Lal Hospital BHU, Varanasi stating the history ofdisease for last 6 months as stated by the patient himself. The complainant deniedthese allegations but did not submit any evidence to controvert these evidencessubmitted by the insurer and as such the repudiation of the claim, being within twoyears from the date the insurance was effected, was held to be in order.Lucknow Ombudsman CentreCase No. : L-350/21/001/06-07Smt. Gayatri DeviVsLife Insurance Corporation of IndiaAward dated 16.01.2007Smt. Gayatri Devi had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy no.214863840 on the life ofher husband Shri Satya Deo Singh on the ground that there was materialnondisclosure/ suppression of material facts regarding the disease of diabetes mellitus,hypertension and dilated cardiomyopathy with which the life assured was suffering forlast 20, 23 and 1 year respectively. The insurer in its support submitted the copies ofmedical attendant certificate and certificate of hospital treatment from KGMU, Lucknowwherein the concerned doctor had recorded past history of illness. As per this historywhich was stated by the patient himself the life assured was suffering from diabetesmellitus for 20 years, hypertension for 23 years and dilated cardio myopathy for 1 year.The complainant submitted her own affidavit and the affidavits of two of her neighboursstating that the deceased life assured was not suffering from any of these diseasesprior to his death but viewing the two evidences it was held that the statement recordedby the doctors of KGMU was more reliable as recording was done by an independentneutral authority whereas the evidences submitted by the complainant were byinterested persons. The repudiation of the claim by the insurer was, therefore, held tobe in order.Lucknow Ombudsman CentreCase No. : L-527/21/001/06-07Shri Sarvjit GuptaVs.Life Insurance Corporation of IndiaAward dated 16.01.2007

Shri Sarvjit Gupta had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy no.292487559 on the life ofhis wife Smt. Simrikha Devi on the ground that in the proposal form she had stated herprofession as being engaged in sewing, weaving and embroidery work whereas shewas a household lady. The insurer submitted copy of statement from few residents ofthe locality including the son of the life assured and from Up-Pradhan of the village toestablish that the life assured Smt. Simrikha Devi was a household lady and was notengaged in any independent occupation or profession. As per insurer household ladiesare not granted insurance unless there is insurance policy inforce on the life of theirhusbands for an equivalent amount which is not so in the present case. Therepudiation, being within two years from the date the policy was effected, was thereforeheld to be in order.Lucknow Ombudsman CentreCase No. : L-421/21/001/06-07Smt. MayawatiVsLife Insurance Corporation of IndiaAward dated 18.01.2007Smt. Mayawati had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy no.252586678 on the life ofher husband Shri Krishna Gopal on the ground that there was material suppression ofillness in the personal statement regarding health submitted for revival of the policy.The insurer relied on medical attendant certificate and certificate of hospital treatmentwherein the duration of illness of vomiting and restlessness was stated to be one yearwhich went beyond the date of personal statement regarding health. However, sincethe claim had been repudiated two years after the date on which the policy waseffected insurer failed to establish that the life assured had the knowledge of thesediseases alleged to have been suppressed nor that the suppression was madefraudulently. Under the circumstances the claimant was entitled to Notional Paid upvalue as per Chairman’s Relaxation Rules.Lucknow Ombudsman CentreCase No. : L-605/21/001/06-07Smt. Geeta DeviVsLife Insurance Corporation of IndiaAward dated 19.01.2007Smt. Geeta Devi had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy no.253053087 on the life ofher husband Shri Lal Bahadur Singh on the ground that he had not disclosed about theailments with which he was suffering prior to the date of the proposal in the proposalform. The insurer in support of its contention submitted copy of certificate of hospitaltreatment and copy of medical attendant from Safdarjang Hospial, New Delhi where theassured had taken the treatment at the time of his terminal illness. As per the historystated by the patient in these certificates, the life assured was suffering from abdomenpain for 1½ years and chest pain for last two years. Since these facts which werewithin his knowledge were not disclosed in the proposal form, the repudiation of theclaim as per Section 45 of the Insurance Act 1938 was held to be in order.

Lucknow Ombudsman CentreCase No. : L-114/21/001/06-07Shri Rupesh Kumar GuptaVsLife Insurance Corporation of IndiaAward dated 19.01.2007Shri Rupesh Kumar Gupta had lodged a complaint with Insurance Ombudsman foralleged unjustified repudiation of claim by LIC of India under policy no.253185825 onthe life of his wife Smt. Anita Gupta on the ground that the fact regarding earliercaesarian delivery was not disclosed in the proposal form by the life assured and thisaffected the underwriting decision of the insurer. If this would have been disclosed shewould have been asked to complete addendum to proposal form as well as to submitreport from attending Gynecologist on form 3341 and also to submit haemogram report.Besides one of the causes of her death was Hepatic Encephalopathy and Hepatitis-Einfection developed during her pregnancy. Since the claim has been repudiated withintwo years from the date the policy was effected. The repudiation of the claim on theabove ground which was established by certificate of hospital treatment and theadmission of the complainant himself during personal hearing was, therefore, held tobe in order.Lucknow Ombudsman CentreCase No. : L-544/21/001/06-07Shri JitendraVsLife Insurance Corporation of IndiaAward dated 22.01.2007Shri Jitendra had lodged a complaint with Insurance Ombudsman for alleged unjustifiedrepudiation of claim by LIC of India under policy no.283695944 on the life of his motherSmt. Durga Devi on the ground that she was suffering from Anemia and Renal diseasesprior to the date of the proposal but she did not disclose the same in the proposal form.However, no cogent evidence to establish the fact of nondisclosure of the disease wasproduced by the insurer so as to establish that conditions of Section 45 of InsuranceAct 1938 were complied with. The letter of repudiation was, therefore, set aside andthe complainant nominee awarded full payment of claim alongwith accrued bonuses.Lucknow Ombudsman CentreCase No. : L-562/21/001/06-07Shri Nanhe Lal YadavVsLife Insurance Corporation of IndiaAward dated 22.01.2007Shri Nanhe Lal Yadav had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy no.283592436 on the life ofhis wife Smt. Phoolwati Yadav on the ground that in the personal statement regardinghealth dated 09.11.05 submitted for revival of the above policy the life assured hadsuppressed the ailments with which she was suffering prior to the date of the revival.The Insurer however did not submit any evidence in support of his repudiation actioneven although 15 days time as further sought by its representative on the date ofpersonal hearing for the purpose had elapsed by a sufficient margin. The repudiationletter dated 03.05.06 issued by the insurer was, therefore, set aside and nominee

complainant awarded payment of full sum assured alongwith accrued bonus under thepolicy.Lucknow Ombudsman CentreCase No. : L-628/21/001/06-07S/Shri Pramod, Anil & Praveen KumarVsLife Insurance Corporation of IndiaAward dated 22.01.2007S/Shri Pramod, Anil and Praveen all brothers had lodged a complaint with InsuranceOmbudsman for alleged unjustified repudiation of claim by LIC of India under policyno.252721135 on the life of their brother Shri Rampal Singh on the ground that theinsurer was not informed about his change in health condition of the life assured aftersubmitting the personal statement regarding health for revival of the policy. He hadsuffered from Jaundice 15 days before the date of his death as per the certificate ofHospital treatment and certificate of medical attendant issued by Jeevan Hospital, NewDelhi. The history of the disease as per these certificates was stated by the closerelatives. Since no sufficient reasons were advanced by the complainants for notrelying on certificates and no other evidence was adduced to controvert the evidencefurnished by the insurer it was decided not to interfere with the decision of the insurerto pay paid up value + bonus amounting to Rs.36,150/- under the policy to thecomplainant.Lucknow Ombudsman CentreCase No. : L-661/21/001/06-07Smt. Krishna SharmaVsLife Insurance Corporation of IndiaAward dated 31.01.2007Smt. Krishna Sharma had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy nos. 221922645,221922646 & 221922997 on the life of her husband Shri Rajeev Sharma on the groundof material nondisclosure of illness of diabetes, CAD & CHF with which he wassuffering, in the proposal form. The insurer in support of its contention submitted copyof hospital treatment and OPD case file from SGPGI, Lucknow which recorded in clearterms that the life assured had a history of diabetes for 17 years, hypertension 2 yearsand swelling of leg for 6 months. Since these diseases were not disclosed in theproposal form obviously with an intention to take an unfair advantage, the repudiationof the claim under the policies was therefore, held to be in order.Lucknow Ombudsman CentreCase No. : L-592/21/001/06-07Shri Deena Nath SharmaVsLife Insurance Corporation of IndiaAward dated 31.01.2007Shri Deena Nath Sharma had lodged a complaint with Insurance Ombudsman foralleged unjustified repudiation of claim by LIC of India under policy no.281379056 onthe life of his wife Smt. Ashrafa Devi on the ground that while reviving the policy on11.03.03 she had not disclosed about the diseases of diabetes mellitus type-II,

hypothyroidism and renal diseases with which she was suffering from. In support of itsdecision the insurer submitted copy of certificate of hospital treatment and certificateof medical attendant from institute of Medical Sciences, BHU, Varanasi wherein it wasstated that the deceased life assured was suffering from type-II diabetes mellitus for 7– 8 years and hypothyroidism for 3 years and chronic kidney disease for 3 years.History was narrated by the patient herself and her attendant. There was no reason todisbelieve the recording by the attending doctor of Institute of Medical Sciences, inparticular when no evidence to contradict this was submitted by the complainant. Therevival on 11.03.03 declaring the life assured to be in sound health was therefore madein order to get an unfair advantage and there was, therefore, no reason to interferewith the repudiation letter dated 01.10.05 of the insurer.Lucknow Ombudsman CentreCase No. : L-463/21/001/06-07Smt. Madhwi DeviVsLife Insurance Corporation of IndiaAward dated 31.01.2007Smt. Madhwi Devi had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy no.240681887 on the life ofher husband Shri Dilip Singh Mahar on the ground of nondisclosure of material factsrelating to the details of leave taken on medical ground during last three years by him.The insurer submitted that he had taken 88 days leave on health grounds during lasttwo years on five occasions and submitted copies of leave applications and medicalcertificates in support of its contentions. The complainant contended that since herhusband was a driver in Uttaranchal Parivahan Nigam where it was not possible to getleave otherwise he had to take leave on medical grounds whereas he was not sick onthese occasions but he had taken leave in order to take care of his ailing mother andfor arranging his sister’s marriage. It was, however, observed that the claimant’sstatement was not reliable as the mother of the life assured as per the proposal formhad already expired in the year 1995 and she was also not able to tell as when hersister was married. I therefore, uphold the repudiation action taken by the insurer inrepudiating the claim under the policy as all the ingredients of Section 45 of InsuranceAct 1938 are fulfilled.Lucknow Ombudsman CentreCase No. : L-302/21/001/06-07Smt. Madhwi DeviVsLife Insurance Corporation of IndiaAward dated 31.01.2007Smt. Madhwi Devi had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy nos.240888523 &241226749 on the life of her husband Shri Mohan Lal on the ground that there wasmaterial non disclosure of the illness of CRF/ESRD and pulmonary oedema by thedeceased life assured in the proposal dated 29.05.04 under policy no.241226749 andin the personal statement regarding health dated 17.05.04 submitted for revival ofpolicy no.240888523. The insurer in its support submitted certificates of medicalattendant, certificate of hospital treatment from 16.04.04 to 26.04.04 and BHT fromSusheela Tiwari Memorial Forest Hospital. The complainant also submitted a certificatefrom one Keshav Contractor to the effect that the deceased life assured was working

with him during the period 02.03.04 to 04.05.04. Pradhan, Gram Panchayat, Saal alsostated that he was not suffering from any disease. But on a careful consideration it washeld that these certificates on plain paper do not carry any evidentiary value. TheCertificates produced by Insurer were more reliable.Lucknow Ombudsman CentreCase No. : L-600/21/001/06-07Shri Pyare LalVsLife Insurance Corporation of IndiaAward dated 31.01.2007Shri Pyare Lal had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy no.222137073 on the life ofhis wife Smt. Usha Devi on the ground of nondisclosure of material facts relating to herhealth namely that she had suffered from TB and had taken treatment at TB hospitalHardoi prior to the date of proposal. In support of its contention the insurer submittedcopy of investigation report from its officer Shri A.K. Srivastava alongwith his affidavitconfirming the registration no. X00029/14.07.03 at TB Hospital Hardoi where she wastaking treatment alongwith statements from two residents of the locality. Thecomplainant contended that she was medically examined at the time of acceptance ofher proposal. However, since the medical examination does not absolve the proponentfrom disclosing all material fact relating to his / her health the repudiation of the claimunder the policy which was within 2 years from the date the policy was effected washeld to be in order.Lucknow Ombudsman CentreCase No. : L-506/21/001/06-07Smt. Sohan BiriVsLife Insurance Corporation of IndiaAward dated 31.01.2007Smt. Sohan Biri had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy no.271029649 on the life ofher husband Shri Ram Dass on the ground that there was nondisclosure of materialfacts regarding his illness of progressive weakness of all 4 limbs for last 2 years. Theinsurer in his support submitted copy of medical attendant certificate and certificate ofhospital treatment from St. Stephen’s Hospital, Delhi where the life assured wasadmitted on 23.06.05 and the history there was stated by the patient and his attendant.This was further corroborated by his consultation/ treatment undertaken earlierundertaken at Post Graduate Institute of Medical Sciences and Research, Chandigarh.The complainant on the other hand denied that the life assured was not in sound healthat the time of revival and submitted an affidavit and also contended that he hadundergone a medical examination before the revival was effected. However, since thecontract of Insurance is a contract of utmost good faith and the life assured is undersolemn obligation to disclose all material facts and the medical examination is not asubstitute for this obligation, it was held that the nondisclosure of the illness ofprogressive weakness of the limbs for last 2 years had been established by theevidence submitted by the insurer and as such all the ingredients of Section 45 ofInsurance Act 1938 were fulfilled and the repudiation of the claim was in order.Lucknow Ombudsman Centre

Case No. : L-672/21/001/06-07Smt. Vijay LaxmiVsLife Insurance Corporation of IndiaAward dated 12.02.2007Smt. Vijay Laxmi had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy no.214715916 on the life ofher husband Shri Arjun Prasad on the ground that he had suppressed his illness ofdiabetes and hypertension with which he was suffering prior to the date of proposaland had been taking treatment also. The insurer in support of its contention submittedcopy of death certificate which stated the cause of death amongst others as ‘highsugar, Blood pressure’ and further a letter from her son in his handwriting confirmingthat his father, the deceased life assured was suffering from diabetes and hypertensionfor last few years and taking treatment also. Although he retraced from his havingadmitted the above and stated that it was at the instance of the investigating officer butit appears to be an after thought. The insurer, although, could not submit any directevidence of illness of the life assured but in the circumstances of the case, it wasdecided not to interfere with the decision of the insurer repudiating the claim under thepolicy no. 214715916.Lucknow Ombudsman CentreCase No. : L-553/21/001/06-07Smt. Madhulika SrivastavaVsLife Insurance Corporation of IndiaAward dated 14.02.2007Smt. Madhulika Srivastava had lodged a complaint with Insurance Ombudsman foralleged unjustified repudiation of claim by LIC of India under policy no.231753819 onthe life of her husband Shri Anil Kumar Srivastava on the ground of suppression ofmaterial facts regarding his illness (Ischaemic Heart Disease & Hypertension). ThePolicy had lapsed on account of nonpayment of premium due yearly July, 1998 andagain on July, 2001. It was revived on 02.02.99 and again on 09.07.02 on the strengthof personal statement regarding health made by the life assured on 02.02.99 and03.07.02. On both the occasions the life assured had not disclosed any thing about hisillness and declared himself to be in sound health. The insurer, however, submitted thestatement of leave from his employer alongwith the medical certificates whichestablished that the deceased was on sick leave from 04.06.98 to 20.06.98 forIschaemic Heart Disease, unstable Angina & mild Hypertension. He had again sufferedfrom the same disease and had to be on leave from 16.08.99 to 20.08.99 and 21.10.99to 29.10.99. Since the disease had its onset prior to the date of execution of personalstatement regarding health dated 02.02.99 and the diseases were not disclosed in thepersonal statement regarding health, the repudiation of the claim on the ground ofmaterial misstatement regarding health was held to be in order. The complainantnominee was, however, awarded payment of paid up value acquired after payingpremium up to July 1997.Lucknow Ombudsman CentreCase No. : L-635/21/001/06-07Smt. Shakuntala DeviVsLife Insurance Corporation of India

Award dated 31.02.2007Smt. Shakuntala Devi had lodged a complaint with Insurance Ombudsman for allegedunjustified repudiation of claim by LIC of India under policy no.283869308 on the life ofher son Shri Anand Kumar Soni on the ground that since death had taken place withinone year from the date of commencement of risk under the policy, the suicide clausewas operative and hence nothing was payable. The insurer did not lead any directevidence to establish suicide but from the circumstances contended that the death ofthe life assured was nothing but a case of suicide. It was no doubt established that thedeath of life assured had been caused by taking some poisonous substance. No FIRwas lodged. The punchnama was done and in the opinion of panches he might haveconsumed some poisonous substance by mistake as he was keeping poisonoussubstances with him for cleaning/washing ornaments. However, the complainant’sversion was that he was engaged at a gold smith shop and doing polishing (fNykbZ dkdke) of ornaments and that somebody else would have served him some poisonoussubstance causing his death. However, she could not explain satisfactorily as why noFIR was lodged if she had such a suspicion. Taking an overall view and in the factsand circumstances of the case and that no contrary evidence was produced by thecomplainant, the repudiation of the claim was held to be in order.Mumbai Ombudsman CentreCase No. : LI-221 of 2005-2006Smt Anuradha Ashok DesaiV/s.Life Insurance Corporation of IndiaAward Dated : 04.10.2006Shri Ashok D Desai had proposed for a Money Back Children’s Assurance policywithout profits for his son Mast. Akash Ashok Desai from Life Insurance Corporation ofIndia for a Sum Assured of Rs. 50,000/- with Term Rider Benefit and Premium WaiverBenefit. The date of proposal under the policy was 23.3.2001 and On 21.02.2004 ShriDesai was assaulted while he was on his official duty which caused him serious headinjuries and he finally succumbed on 24.02.2004. The cause of death was Head injurywith Fracture frontal bone with frontal contusion. When Smt Anuradha Ashok Desaiwife of Shri Ashok Desai preferred a claim for premium waiver benefit and Term Riderbenefit under the policy, Life Insurance Corporation of India Goa Divisional Officerejected the benefit stating that Shri Ashok Desai had withheld material informationregarding his health at the time of effecting the assurance. They held indisputableproof to show that Life Assured was suffering from Hypertension, Urinary Calculus,acute gastritis, ureteric stone, growth in urinary bladder, post bely cystitis and urinarytract infection for which he had consulted a medical men and had taken treatment in ahospital and also that he was on medical leave on various occasions for the saidailments. These facts were not disclosed at the time of proposing for the above saidpolicy instead Shri Desai had given false answers as above. Hence LIC rejected theclaim for Premium Waiver Benefit and Term Rider benefit under the policy. Notsatisfied with the decision of the Company, Smt Anuradha A Desai represented to theWestern Zonal Office of the Corporation which was also turned down. Hence beingaggrieved she approached the Office of the Insurance Ombudsman seekingintervention of the Ombudsman for justice. The records were perused and parties tothe dispute were called for hearingIt is evident from the medical certificates on record which were submitted by the LifeAssured to his employer for securing leave on health grounds that he had been

suffering from Hypertension, Urinary Calculus, Acute Gastritis, Ureteric Stone, Growthin urinary bladder, Urinary Tract Infection and Cystitis for which he had consultedmedical men and took treatment for the same and remained absent from his place ofwork on medical grounds before he proposed for assurance. The additional benefitsviz. Term Rider Benefit and Premium Waiver Benefit were granted on the basis ofinformation given by him at proposal stage in the proposal form and other documents.It would appear from the documents on record that the statements made by the lifeassured were inaccurate, false and he deliberately suppressed the facts which it wasmaterial to disclose. Had he disclosed the correct information, additional benefitswould not have been granted under the policy or policy would have been issued withdifferent terms. It is pertinent to note that immediately after the policy was taken ShriAshok Desai suffered from Carcinoma of Bladder and was operated for the same andremained absent from his work place on this ground on many occasions which clearlyindicates the positive existence of the disease before the policy was taken. Thecontention of the Complainant that the cause of death was head injury due to assaultand has no nexus with the illnesses suffered by the life assured before the policy wastaken is not acceptable because it is proved from the documents on record that the lifeassured took the policy suppressing the material facts regarding his health status andwhen the very basis of the contract was on suppressed material facts, the contractbecame void from inception. Based on the facts and the documents produced, thisForum does not find any valid reason to interfere with the decision of LIC. However,the role of the Agent who introduced the business should be examined and appropriateaction should be taken.Mumbai Ombudsman CentreCase No. : LI-147 of 2006-2007Shri Rohidas R SanvordekarV/s.Life Insurance Corporation of IndiaAward Dated : 04.10.2006Miss. Rakhi R Naik Sanvordekar had taken a Life Insurance policy from Life InsuranceCorporation of India, Vasco Branch- 91E,Goa Divisional Office through proposal dated23.03.2001 for a Sum Assured of Rs.40,000/- . Miss Rakhi Naik Sanvordekar (SmtShruti Shesh Shirodkar) expired on 14.04.2005 at KLE Society’s Hospital and MRC,Belgaum, Karnataka Department of Clinical Immunology and Rheumatology due toAcute Respiratory Distress Syndrome with FTC SLE with Pulmonary Tuberculosis.When the claim for the policy moneys was preferred to Life Insurance Corporation ofIndia by her father Shri Rohidas R Sanvordekar who was the nominee under the policyit was held by Goa Divisional Office that they had indisputable evidence to show thatthe deceased life assured was suffering from Systemic Lupus Erythematosus beforeshe proposed for the policy which was not disclosed while filling the proposalformAggrieved by this decision, Shri Sanvordekar approached this Forum for redressalof his grievance. After perusal of the records parties to the dispute were called forhearing on 27.9.2006 at Ombudsman’s Camp at Goa. It is evident from the claim formB and Claim Form B1 issued by Dr. Arun Shrivastava of KLE Society’s Hospital and thedischarge summaries of the same hospital on record that the deceased life assuredhad been suffering from Systematic Lupus Erythematosus since 1993. She did notdisclose this material information in her proposal dated 23-3-2001, instead, she gavedeliberate incorrect statements. The proposal was on non-medical basis and nomedical examination was conducted and as such LIC solely relied on the informationgiven in the proposal form and the health declaration given by the insured and on the

asis of which proposal was completed. As per the declaration, the insured was dutybound to disclose all the information correctly and truthfully at the time of proposing forassurance. However, she did not disclose her past illnesses and the treatment taken byher in the proposal form deliberately which was material for underwriting her proposal.In view of this legal position and the convincing evidence produced by LIC, thedecision of L.I.C to repudiate the death claim on the ground that the deceased lifeassured made wrong statements and withheld correct information regarding the healthat the time of effecting insurance cannot be faulted. In the circumstances, this forumfinds no valid reason to interfere with the decision of L.I.C to repudiate the claim forthe sum assured under the policy.Mumbai Ombudsman CentreCase No. : LI-217 of 2005-2006Smt.Roshan Ramakant NaikV/s.Life Insurance Corporation of IndiaAward Dated : 05.10.2006Shri Ramakant Fondu Naik had taken three Life Insurance policies from Life InsuranceCorporation of India, Goa Divisional Office. One policy lapsed due to non-payment ofpremium in November, 2000 which was revived on 22.10.2001 on the basis of thedeclaration of Good Health dated 22.10.2001.Shri Ramakant Fondu Naik unfortunatelyexpired on 4 th August, 2004, due to Haemorrhagic Pericardial Effusion c CardiacTamponade (Primary Cause) and Diabetic Nephropathy (Secondary Cause). When SmtRoshan Ramakant Naik, wife and nominee under the policies, preferred claim under theabove said policies to Life Insurance Corporation of India, LIC of India, Goa D.O.repudiated the liability stating that the deceased life assured had withheld correctinformation regarding his health at the time of effecting the assurance/at the time ofrevival, and hence, in terms of the policy contract and declaration in the proposal formand personal statement, they were not liable for any payment under the policies. Notsatisfied with this decision, the claimant, Smt Roshan Ramakant Naik made arepresentation to the Zonal Manager of Western Zone of LIC of India, but the ZonalOffice Claims Review Committee also upheld the decision taken by the DivisionalOffice. Aggrieved by their decision, Smt Roshan Ramakant Naik approached this Forumfor justice.After perusal of the records parties to the dispute were called for hearing. The recordssubmitted to this Forum pertaining to the case have been scrutinised. It is evident fromthe records that the deceased life assured had been suffering from Diabetes Mellitusand Hypertension when he proposed for the new policies and also revival of his lapsedpolicy. The life assured died due to Diabetic Nephropathy with Chronic Renal Failure.The Life Assured did not disclose these facts in the proposals and also in theDeclaration of Good Health submitted by him for revival of his policy. In view if thislegal position, LIC cannot be faulted for repudiating the claim of Smt. RoshanRamakant Naik. In the circumstances, this Forum finds no justifiable reason to interferewith the decision of LIC to repudiate the claims.Mumbai Ombudsman CentreCase No. : LI-025 of 2006-2007Smt. Victorine FernandesV/sLife Insurance Corporation of India

Award Dated : 6.11.2006Shri Floyd Fernandes had proposed for a Money Back policy from Mumbai D.O.IV, LifeInsurance Corporation of India, bearing policy no. 905037940. The date of proposalunder the policy was 15.02.2004 and the date of commencement of the policy was19.02.2004. Shri Fernandes expired on 14.03.2005 due to Cardio Respiratory Arrest.When the claim was preferred by Smt Victorine Fernandes wife of LA, Life InsuranceCorporation of India rejected the claim stating that Shri Fernandes had withheldmaterial information regarding his health at the time of effecting the assurance.LIC took the view that all the statements were false and stated that they heldindisputable proof to show that since about 2 years back before he proposed for thepolicy he had been suffering from Chronic Bronchitis and was a chronic smoker and hewas also suffering from COPD since January,2003. These facts were not disclosed atthe time of proposal, instead he gave false answers as stated above. It is therefore,evident that the deceased life assured had made deliberate mis-statements and withheldmaterial information from LIC regarding his health at the time of effecting theassurance and therefore in terms of the policy contract and the declarations containedin the forms of proposal for Assurance, LIC repudiated the claim.As per Medical Attendant’s Certificate issued by Dr. Ashok Moses, the primary cause ofdeath was Cardio-Respiratory Arrest. The Doctor attended the deceased after heexpired. He has also mentioned that the other disease or illness preceded/coexistedwith that which immediately caused his death was COPD which was first observed inJanuary, 2003 and was treated by him. The doctor has also stated that he was hisusual medical attendant since 2-3 years. Based on the information given in Claim FormB and the Certificate dated 9.9.05 issued by Dr. Ashok Moses, it is evident thatdeceased life assured was suffering from Chronic Obstructive Pulmonary Disease andChronic Bronchitis for which he took treatment from Dr. Ashok Moses . Dr. Moses hadalso stated that the Life Assured was a chronic smoker. As per the declaration, theinsured was duty bound to disclose all the information correctly and truthfully at thetime of proposing for assurance. In view of the legal position, the decision of L.I.C torepudiate the death claim on the ground that the deceased life assured made wrongstatements and withheld correct information regarding the health at the time ofeffecting insurance cannot be faulted.Mumbai Ombudsman CentreCase No. :LI-136 of 2006-2007Smt Geeta V ShettyV/s.Life Insurance Corporation of IndiaAward Dated : 09.11.2006Shri Vijay Vasu Shetty had taken a Life Insurance policy bearing no.902027528 fromLife Insurance Corporation of India, Branch 927 of Mumbai Divisional Office-I throughproposal dated 08.05.2002 for a Sum Assured of Rs.1,00,000/- under Plan and Term(75-20. Unfortunately Shri Vijay Shetty expired on 10.03.2005 due to CardioRespiratory Arrest being the primary cause and the secondary cause beingSepticaemia with chronic bronchitis and Asthma. When Smt Geeta Shetty, wifepreferred a claim LIC repudiated the claim stating that the deceased life assured hadwithheld material information regarding his health at the time of effecting theassurance. After perusal of all the records submitted to this Forum parties to thedispute were called for hearing. LIC repudiated the claim solely relying on theinformation given by Dr. Pradeep Pawar in Claim Form B and Certificate of

Consultation/Treatment as proof of past illnesses i.e. Bronchitis & Asthma allegedlysuffered by the life assured since 25 years. It is to be noted that as per the informationgiven by the above doctor, he had been practicing in that area since 5 years and hewas first consulted by the deceased on 2.2.2002. Though the doctor has mentionedthat past history was given by him as reported by the patient himself, LIC has notbrought on record any additional material to prove the history of Bronchitis andAsthma, prior to the date of proposal by way of treatment particulars/ pathologicalreports/doctor’s prescription/hospitalisation record for the said illnesses or even thesick leaves from the employer. When two statements are obtained from the samedoctor regarding the life assured, one in favour and one against, the one which isprejudicial to the interest of the person cannot be relied upon, unless there aresupportive evidences. Hence the history of 25 years stated by Dr. Pawar cannot betaken cognizance of.As the statutory period of two years had clearly expired when LICrepudiated the claim, Section 45 of the Insurance Act, 1938 applies in the present caseand policy cannot be called in question only on the ground of misstatement.In view of the above analysis, I find that the repudiation of the claim by LIC of India isnot sustainable on the basis of the documents produced before this Forum by them insupport of their decision to repudiate the claim under policy no. 902027528 for nondisclosureof material facts and hence the said decision of LIC is sustainable.Mumbai Ombudsman CentreCase No. :LI-141 of 2006-2007Smt Meena S PangareV/s.Life Insurance Corporation of IndiaAward Dated : 15.11.2006Shri Shantaram Gangaram Pangare had taken a Life Insurance policy through proposaldated 02.02.2005 for a Sum Assured of Rs.50,000/-.Shri Shantaram G Pangare expiredon 03.10.2005 due to Cardio Respiratory Arrest. When Smt Meena Pangare, wife andnominee under the policy, preferred a claim under the above said policy to LifeInsurance Corporation of India, Mumbai Divisional Office-I repudiated the claim statingthat the deceased life assured had withheld material information regarding his health atthe time of effecting the assurance. Aggrieved by this decision of LIC even afterrepresentation, Smt Meena Pangare approached this Forum seeking intervention of theOmbudsman in the matter of settlement of her claim. After perusal of all the recordssubmitted to this Forum, parties to the dispute were called for hearing. On scrutiny ofthe records it is noted that the diagnosis arrived at the hospital was Cor Pulmonale in ak/c/o right destroyed lung with RVH with LRTI which is corroborated by the DischargeCard of the hospital on record. As per the Medical Attendants Certificate (Claim FormB) dated 9 th February, 2006 completed by Dr. Rajesh M. Binyala, the cause of deathwas Cardio-respiratory arrest and the patient had been suffering from the last illnesssince one year, date of first consultation being 5.1.2005. The doctor in a separatecertificate mentioned that the life assured had been suffering from COPD (ChronicObstructive Pulmonary Disease) since one year.” It is also established from the claimform B and BI completed by Dr. Rajesh M. Binyala that he was treated by him for aboveailments before he proposed for assurance. In the instant case , the life assured didnot disclose the material facts regarding his past illness and hospitalisation for thesame, which were especially within his personal knowledge and it deprived LIC ofasking leading questions to probe into the matter. In view of this, L.I.C cannot befaulted for repudiating the death claim for deliberate misstatement and suppression of

material facts by the life assured. Hence the decision of L.I.C does not warrant anyinterference from this forum.Mumbai Ombudsman CentreCase No. : LI-151 of 2006-2007Shri Kevalchand R JainV/s.Life Insurance Corporation of IndiaAward Dated : 17.11.2006Shri Sanjay Kewalchand Jain had taken two Life Insurance policies bearing nos.881094565 and 881094566 from Life Insurance Corporation of India through proposaldated 28.09.2002 for Sum Assured of Rs.3,00,000/- and Rs. 1,00,000 under Plan andTerm (149-25) and (105-30) (25) respectively. The commencement of the policies werefrom 01.10.2002. Unfortunately Shri Sanjay K Jain expired on 28.09.2003 due toTerminal Cardio Respiratory Arrest being the primary cause and the secondary causebeing Bilateral extensive Koch’s . When Shri Kevalchand Jain, father and nomineeunder the policy, preferred a claim under the above said policies to Life InsuranceCorporation of India, Mumbai Divisional Office-II, Life Insurance Corporation of Indiarepudiated both the claim vide letters dated 31.03.2004 stating that the deceased lifeassured had withheld material information regarding his health and that the LifeAssured was admitted to Radhibai Watumull Global Hospital on 29.8.2002 i.e. beforethe date of proposal and was diagnosed to have HIV positive for which he consulted amedical man and had taken treatment from him. This fact was not disclosed at the timeof taking the policy. Hence based on this LIC repudiated the claim. Not satisfied by thesaid decision, Shri Kevalchand Jain appealed to the Zonal Manager and aggrieved ShriKevalchand Jain approached this Forum for redressal of his grievance. Afterscrutinizing the records produced to this Forum, parties to the dispute were called forhearing.The entire records pertaining to the case have been gone through. It is evidentfrom the Radhibhai Watumall Global Hospital Case Papers on record that the deceasedLife Assured was admitted to that hospital on 29.08.2002 and discharged on24.09.2002 and was diagnosed HIV+ and was treated for the same. The fact that duringhis hospitalisation and immediately before that he had undergone various pathologicaltests and was in the hospital for 27 days continuously points to the serious nature ofthe illness he had been suffering. From the above analysis, it is established beyonddoubt that the deceased life assured suppressed material information and mademisstatements regarding his health status at the time of proposal and also suppressedthe material information regarding his health status at time of proposing for assurance.Had he disclosed these facts to the Insurer, they would have probed further and calledfor relevant special reports before taking appropriate decision in acceptance of therisk.In the circumstances, this forum finds no valid reason to interfere with the decision ofLIC of India to repudiate the claim for the sum assured under the policy.Mumbai Ombudsman CentreCase No. : LI-192 of 2006-2007Shri Kanaiya GhoshV/s.Life Insurance Corporation of IndiaAward Dated : 23.11.2006

Smt Shantona Kanaiya Ghosh had taken a Life Insurance policy bearing no. 881033788from Life Insurance Corporation of India through proposal dated 22.02.2002 for a SumAssured of Rs. 1,00,000 under Plan and Term (75-20). The commencement of thepolicy was from 1.01.2002 under half-yearly mode of payment. However the said policylapsed due to non payment of premium due in July, 2003 & January,2004. The policywas revived by LIC on 16.02.2004.Smt Shantona K Ghosh expired on 10.09.2004 dueto Chronic Renal Failure and when Shri Kanaiya Ghosh, husband and nominee underthe policy, preferred a claim under the above said policy to Life Insurance Corporationof India, Mumbai D.O.II of Life Insurance Corporation of India repudiated the claim videletter dated 26.11.2005 stating that the deceased life assured had withheld materialinformation regarding her health in the Personal Statement. After scrutinizing therecords produced to this Forum, parties to the dispute were called for hearing. It isevident from the Certificate of Treatment issued by Dr.Vaishali R Sankholkar that thedeceased life assured was suffering from recurrent attacks of urinary tract infectionsince the last eight to nine months prior to the date of her death and had consulted thedoctor in December, 2003. It is established that she was under treatment for the sameat the time of reviving her lapsed policy The analysis of the entire records leads to theconclusion that the insured had experienced frequent complications of urinary tractinfection which were giving enough signals to contact medical practitioner fortreatment. Riddhi Diagnostic Centre’s receipt indicates that she was indoor patient inWard 4 of KEM Hospital and was referred by the hospital for HCV Elisa test on 9-3-2004. As the Complainant has not produced the details of the first hospitalisation inKEM hospital, it is difficult to ascertain the exact date of admission and the history ofthe illness reported to the hospital. But, the date of reference for HCV test by Ward 4of KEM Hospital was 9-3-2004 which is close to the date of revival of the policy on 13-2-2004. From the above analysis, it would be reasonable to conclude that she hadhealth problems at the time of revival of the policy and it was known to her. All thesewere material facts, which should have been disclosed at the time of revival of thepolicy. Had she disclosed the correct information to the Insurer at the revival stage,LIC of India would have considered the revival with different criteria on the basis of thespecial medical reports, which would have been called for. The information suppressedin this case was material since the diseases connected with organs such as Kidney,Heart and Brain affect the longevity of a person.In the facts and circumstances of the case, decision of LIC to treat the revival of thepolicy as null and void is sustainable. Hence this Forum has no justifiable reason tointerfere with the decision of LIC.Mumbai Ombudsman CentreCase No. : LI-246 of 2006-2007Smt Samaradevi PatelV/s.Life Insurance Corporation of IndiaAward Dated : 28.11.2006Shri Ram Lakhan R Patel had taken a Life Insurance policy bearing no.892632594 fromLife Insurance Corporation of India, Branch 891 of Mumbai Divisional Office-III throughproposal dated 11.12.2003 for a Sum Assured of Rs.1,00,000/-. The commencement ofthe policy was from 21.08.2003. Unfortunately, Shri Ram Lakhan Patel expired on28.09.2005 due to Hypotension due to chronic renal failure in case of Diabetes Mellitusand Hypertension. When Smt Samradevi Patel, wife and nominee under the policy,preferred a claim under the above said policy to Life Insurance Corporation of India,Mumbai Divisional Office-III of Life Insurance Corporation of India repudiated the claim

stating that the deceased life assured had withheld material information regarding hishealth at the time of effecting the assurance. Not satisfied by the said decision SmtSamradevi Patel appealed to the Zonal Manager aggrieved at their decision, SmtSamradevi Patel approached this Forum for redressal of her grievance. After perusal ofall the records submitted to this Forum parties to the dispute were called for hearing .Itis evident from the above case papers that the deceased Life Assured, Shri Patel, wassuffering from Hypertension since three years before his death and the SonographyReport dated 27.8.2003 from Sadguru Daskishan Saibaba Mandal Charitable Polyclinicrevealed that there was stone in his left kidney. The fact that the had undergonevarious pathological tests on 23.8.03 and Ultrasonography on 27.8.2003 as is evidentfrom the history noted in the KEM hospital case papers which were not disclosed byShri Patel at the time of filling up his proposal for insurance. The analysis of the entirerecords leads to the conclusion that Shri Patel had the knowledge that he was sufferingfrom some health problem for which he underwent sonography and some pathologicaltests. He suppressed this material information in his proposal form and gave deliberateincorrect statements. Going by the primary cause of death, i.e., Hypertension withrenal calculi, both the diseases were pre-existing, i.e., they were present even beforethe proposal date as is evident from the KEM hospital case papers. This clearlyindicates that the deceased life assured, with malafide intention, suppressed hismedical history thereby denying LIC an opportunity to take a proper underwritingdecision.In view of this legal position, LIC cannot be put to fault for repudiating theclaim on the life of Late Shri Ramlakhan Patel. In the circumstances, this Forum has nojustifiable reason to interfere with the decision of LIC to repudiate the claim.Mumbai Ombudsman CentreCase No. : LI-150 of 2006-2007Smt Dhan Razia DeviV/s.Life Insurance Corporation of IndiaAward Dated : 29.11.2006Shri Ram Prasad Gupta had taken a Life Insurance policy bearing no. 192533832 fromLife Insurance Corporation of India, Branch 159 of Jaipur Divisional Office throughproposal dated 28.03.2004 for Sum Assured of Rs.51,000/. The commencement of thepolicy was 28.04.2004. Shri Ram Prasad Gupta expired on 01.06.2004 due to Chronicliver disease with Portal hypertension. When Smt Dhan Razia Devi, wife and nomineeunder the policy, preferred a claim under the above said policy to Life InsuranceCorporation of India, S.S.S Divisional Office of Life Insurance Corporation of Indiarepudiated the claim stating that the deceased life assured had withheld materialinformation regarding his health at the time of effecting the assurance Not satisfied bythe said decision, Smt Dhan Razia Devi appealed to the Zonal Manager and beingaggrieved at their decision, Smt Dhan Razia Devi approached this Forum for redressalof her grievance. After perusal of the records parties to the dispute were called forhearing.On an analysis of the entire records, it is observed that the Life Assured hadtwo policies and LIC had settled the claim under policy no.192443156 but for the policyNo. 192533832 which is under dispute at this Forum it is found that LIC had repudiatedthe claim based on the Medical Attendant’s Certificate i.e. Form ‘B’ and the certificateof treatment issued by Dr. P.K.Sanma of Guwhati Medical College.In the claim Form B(Medical Attendant’s Certificate) dated 11.6.2005, Dr. P.K.Sanma has mentioned thePrimary cause of death as Chronic liver disease with Portal Hypertension and for thequestion how long had he been suffering from this disease before his death he replied“for few months exact time not noted”. He has also stated that there was swelling of the

ody with altered behavior for few months. Regarding any reason to suspect thedisease was caused or aggravated by his intemperate habits, the doctor has mentionedthat it ‘may be’ and there was no definite proof regarding the history of alcoholism. Asper the Medical Case sheet if 165 MH C/o 99 APO Hospital there is a noting made on18.5.04 that Shri Ram Prasad was a case of Ascites for one month and an old historyof chronic alcohol intake. The proposal is dated 28.3.04 and was accepted by LIC onlyon 28.04.04 on receipt of first premium. The notings made in the hospital case sheeton 18.5.04 clearly proves that life assured was not in good health and was sufferingfrom ascites before the proposal was accepted by LIC. This information was neitherdisclosed in his proposal form dated 28.3.2004 nor thereafter before acceptance of theproposal. He had furthermore not declared in the proposal form that he used toconsume alcohol. Had he disclosed these material facts at the time of proposing forassurance, LIC would have called for relevant reports and taken appropriate decisionbefore accepting the risk. This opportunity was not given to LIC.Thus rejection of death claim by LIC for the sum assured under the policy for deliberatemisstatement and withholding material information at the time of proposing forassurance is held sustainable. Hence, this Forum finds no justifiable reason tointerfere with the decision of LIC of India.Mumbai Ombudsman CentreCase No. : LI-137 of 2006-2007Smt Jayshree N DhadwadV/s.Life Insurance Corporation of IndiaAward Dated : 04.12.2006Shri Nandkumar Lumaji Dhadwad had taken a Life Insurance policy bearingno.908841608 from Life Insurance Corporation of India, Branch 902 of MumbaiDivisional Office through proposal dated 05.01.2005 for a Sum Assured ofRs.2,00,000/-. The commencement of the policy was from 08.01.2005. Unfortunately,Shri Nandkumar L Dhadwad expired on 24.06.2005 due to Abdominal Koch’s andRetroviral disease. When Smt Jayshree N Dhadwad, wife, preferred a claim under theabove said policy to Life Insurance Corporation of India, SSS Divisional Office, Mumbaiof Life Insurance Corporation of India repudiated the claim stating that the deceasedlife assured had withheld material information regarding his health at the time ofeffecting the assurance.Not satisfied by the said decision Smt Jayshree Dhadwadappealed to the Zonal Manager and aggrieved by their decision, Smt JayshreeDhadwad approached this Forum for redressal of her grievance. After perusal of all therecords submitted to this Forum parties to the dispute were called for hearing. Theentire documents on records and respective submission of the parties have been gonethrough. It is also evident from the certificate by the employer and the medicalcertificates submitted by the life assured for securing leave that he consulted doctorsand remained absent on medical grounds on four occasions before he submitted theproposal. The history recorded in Nair hospital as recorded by the doctor reveals thathe was a chronic alcoholic and smoker. Since the proposal was made under nonmedicalscheme, LIC solely relied on the information given by the life proposed in theproposal form and declaration dated 05.01.2005 for considering the proposal. He didnot disclose the above information in the proposal form which were material insteadreplied the relavant questions negatively. Had he disclosed the true and correctinformation to the Insurer, they would have called for medical reports and relevantquestionnaire and probed further and taken appropriate underwriting decisionaccordingly.

Thus rejection of death claim by LIC of India for deliberate misstatement andwithholding material information regarding health and habits of the life assured at thetime of proposing for assurance under the above policy is held sustainable. Hence, thisForum finds no justifiable reason to interfere with the decision of LIC of India.Mumbai Ombudsman CentreCase No. : LI-036 of 2006-2007Smt Sangita Manish RuiaV/s.HDFC Standard Life Insurance Company Ltd.Award Dated : 05.12.2006Shri Manish Ruia had taken a HDFC Children’s Double Benefit Plan bearingno.000000344373 from HDFC Standard Life Insurance Company Ltd through proposaldated 23.03.2004 for a Sum Assured of Rs.4,00,000/-Unfortunately Shri Manish Ruiaexpired on 03.01.2006 due to Cardio Respiratory Arrest, primary cause beingGlioblastoma multi forme. When Smt Sangita M Ruia, wife and Appointee under thepolicy, preferred a claim under the above said policy to HDFC Standard Life InsuranceCompany Ltd, they repudiated the claim stating that the deceased life assured hadwithheld the information of the diagnosis of Abdominal Koch’s in February, 2004 andabout the Anti Koch’s treatment he received. Not satisfied by the said decision SmtSangita M Ruia appealed to the Grievance committee for reconsideration of thedecision, however the Company reiterated their stand of repudiation. Aggrieved by thisdecision, Smt Sangita M Ruia approached this Forum seeking intervention of theOmbudsman in the matter of settlement of her claim.After perusal of all the recordssubmitted to this Forum, parties to the dispute were called for hearing. The relevantrecords pertaining to the case have been perused and it is evident from the casepapers that the deceased Life Assured, Shri Ruia, was suffering from AbdominalKoch’s disease since February, 2004. i.e. before the date of policy and that he wastaking Anti koch’s treatment right from February, 2004, was not disclosed by the lifeassured in his proposal dated March 23, 2004. Although the cause of death is“Glioblastoma Multiforme, left temporal”(which means a malignant tumour in the brain),which has no known nexus with abdominal koch’s disease, as contended by theComplainant, yet, had Shri Ruia disclosed the correct information about hispast/present history of illness as also the treatment being taken by him to the Insurerat the proposal stage, HDFC Standard Life Insurance Company would have postponedthe proposal and would have reconsidered issuing the policy only after he wascompletely cured of the said disease after calling for relevant medical reports as pertheir underwriting norms. Smt. Sangita Ruia’s contention that her husband was curedof the abdominal koch’s disease after taking treatment for four months does not holdground as the hospital papers and discharge summary (which was issued in earlyJanuary, 2005) reveal that he was on treatment for the same since ten months. Eventhe prescriptions of Dr. Rohini Choughale submitted by the Complainant subsequentlyproves that the deceased life assured was on treatment for T.B. till 2.3.2005. Asregards the nexus between the cause of death and the illness suffered prior to takingpolicy, the same need not be established as it would be sufficient to prove themateriality of the suppressed information, which actually affected the assessment ofthe risk, by the Insurer. In this case from the above facts and the related documentsproduced by the Respondent it is clear that the deceased life assured was aware of theabdominal Koch’s disease he was suffering and he deliberately did not disclose thefact in the proposal form which was material to assess the risk by the Insurer.

Mumbai Ombudsman CentreCase No. : LI-030 of 2006-2007Smt Yogita Y SingasaneV/s.Life Insurance Corporation of IndiaAward Dated : 07.12.2006Shri Yashwant Maniram Singasane had taken a policy from Life Insurance Corporationof India, Branch 936 of Thane Divisional Office through proposal dated 08.02.2004 fora Sum Assured of Rs.30,000/- by making a single premium payment of Rs.25,765. ShriYashwant Maniram Singasane expired on 11.02.2005 due to Terminal Cardiorespiratory failure due to septicemia in a case of arterial and Venous gangrene in caseof post. op coronary artery by pass graft with cellulites. When Smt Yogita Y Singasane,wife preferred a claim under the above said policy, Life Insurance Corporation of Indiarepudiated the claim stating that the deceased life assured had withheld materialinformation regarding his health at the time of effecting the assurance. Not satisfied bythe said decision Smt Yogita Singasane approached this Forum. After perusal of all therecords submitted to this Forum, parties to the dispute were called for hearing. Therecords pertaining to the case have been analysed. It is apparent from the medicalrecords that Shri Yashwant Singasane had undergone Angiography and CABG on18.9.03 and 23.9.03 respectively and this information which was vital was not disclosedby Shri Singasane at the time of taking the policy. Had he disclosed these facts at thetime of proposal, LIC would have called for relevant special reports and takenappropriate underwriting decision. Hence LIC’s repudiation of the claim on the groundof withholding material information regarding his health is legally justified.However, the complaint of Smt Yogita Singasane has to be examined in the light of thecircular ref: Mktg/CRM/550/23 dated 13.12.2005 issued by Central Office of LIC. As perthis circular, where it is established that if there was no intention of the deceased todeliberately misrepresent/suppress facts, an ex-gratia payment may be considered onthe basis of merit of the case, maximum to the extent of 90% of the single premium. Itis to be noted that after the claim was repudiated by the Divisional Office the claimant,Smt Yogita Singasane had represented her case to the Zonal Claims ReviewCommittee and it appears that the Zonal Claims Review committee in April, 2006before upholding the decision did not take into consideration the said circular.In theinstant case, the sum assured under the policy was Rs. 30,000 and the life assuredhad paid premium of Rs. 25,765. On the face of it, it appears that the life assured tookthe policy for investment purpose rather than risk cover and as such there is no reasonto presume that he deliberately misrepresented or suppressed the facts intentionally.The deceased did not propose for high risk policy or high Sum Assured looking to hishealth conditions. By pass surgery scars are apparently visible on the chest and it wasnot pointed out in the medical report and Agents report. Looking to these facts, denialof Ex-gratia is not justified.The claim of Smt Yogita Y Singasane under policy no.923046312 on the life of late ShriYashwant Maniram Singasane is not tenable. However, in view of delay in consideringex-gratia payment, LIC is directed to pay an ex-gratia payment of 95% of the singlepremium collected by them.Mumbai Ombudsman CentreCase No. : LI-157 of 2006-2007Smt Rupali Shivaji PolV/s.

Life Insurance Corporation of IndiaAward Dated : 11.12.2006Shri Shivaji Vishnu Pol had taken a Life Insurance policy bearing no. 907499727 fromLife Insurance Corporation of India, Branch 927 through proposal dated 30.07.2003 forSum Assured of Rs.75,000/ under Plan and Term (14-15). The commencement of thepolicy was 20.08.2003. Shri Shivaji V Pol expired on 29.12.2004. When Smt Rupali SPol wife and nominee under the policy, preferred a claim under the above said policy toLife Insurance Corporation of India, S.S.S Divisional Office of LIC repudiated the claimstating that the deceased life assured had withheld material information regarding hishealth at the time of effecting the assurance and in the proposal form dated 30.7.2003They said they had indisputable proof to show that the Life Assured was suffering fromJuvenile diabetes since age 12-13 years and was on insulin. He was also a case ofchronic pancreatitis. These facts were not disclosed at the time of taking the policy.Hence based on this LIC repudiated the claim. Not satisfied by the said decision, SmtRupali S Pol approached this Forum for redressal of her grievance. After perusal of therecords parties to the dispute were called for hearing. The relevant records pertainingto the case have been perused.It is evident from the history recorded in the casepapers of KEM hospital and Jaslok hospital that Shri Shivaji Pol was javelin diabeticsince age 12/13 years.It can be established that the above facts were not disclosed inhis proposal dated 30 th July, 2003. The analysis of the records leads to the conclusionthat the deceased life assured had fraudulently suppressed material information in hisproposal form; instead, he gave deliberate incorrect statements. Since he was takinginsulin for diabetes, he was very much aware of it. The cause of death, viz.,“Carcinoma, Head of Pancreas”, has a direct nexus with the suppressed materialinformation. “Chronic Pancreatitis may lead to pancreatic failure causing malabsorptionand diabetes mellitus. The pancreas often becomes calcified producing visibleshadowing on X rays”. The above is extracted from the Oxford’s Concise MedicalDictionary, Indian Edition. Had Shri Pol disclosed the correct information about hispast/present history of illness as also the treatment being taken by him, to the Insurerat the proposal stage, the Life Insurance Corporation of India would have called forvarious special reports before underwriting the proposal and taken appropriate decisionin acceptance of the proposal.In the circumstances, this Forum has no justifiable reason to interfere with the decisionof LIC of India to repudiate the claim on the ground of non-disclosure of materialinformation.Mumbai Ombudsman CentreCase No. : LI-232 of 2006-2007Smt JayalaxmiV/s.Tata AIG Life Insurance Company Ltd.Award Dated : 28.12.2006Shri Alva Ramayya Santha had taken a Term Assurance Policy for 20 years with returnof premium plan under policy No.C001840670 from Tata AIG Life Insurance Companylimited for a Sum Assured of Rs. 2,00,000/-. The policy also covered an additionalAccidental death benefit of Rs. 2,00,000/-, The date of proposal for insurance was26.10.2005. Shri Alva Ramayya Santha unfortunately expired on 18.1.2006 due toTerminal Cardiac Arrest in a case of Orbital Mucor-mycosis with Diabetes Mellitus withstroke. When Smt Jayalaxmi preferred a claim under the said policy, the Companyrepudiated the claim stating that Shri Ramayya Santha Alva was on insulin therapy for

Diabetes Mellitus since 20 years and this was not disclosed at the time of taking thepolicy. Not satisfied with the decision of the Company Smt Jayalaxmi approached theOffice of the Insurance Ombudsman. After perusal of the records parties to the disputewere called for hearing. It is evident from the history recorded by the doctor at the timeof admission to KEM Hospital that the deceased life assured was suffering fromdiabetes for a long time and was on Insulin. The case papers of Holy Family Hospitalalso reveals that he was a known case of IHD, DM, HTN, ARF and the diagnosisarrived at Holy Spirit Hospital was uncontrolled diabetes mellitus and acute renalfailure and was advised dialysis urgently. The analysis of the medical records leads tothe conclusion that the Diabetes Mellitus which the deceased life assured was sufferingmust have contributed for worsening of the condition of the life assured and it was inexistence before making the application for insurance. The duration of D.M. can bedebated as other than hospital record no evidence was produced but certainly thepresent stage can’t develop in two months, the history certainly goes back prior to thisperiod and since he was taking insulin for D.M. so it was also known to him. As suchthe contention of the complaint that the deceased was not suffering from DiabetesMellitus is not sustainable.In the circumstances, this forum finds no valid reason to interfere with the decision ofTATA AIG Life Insurance Co. to repudiate the claim for the sum assured under thepolicy.Mumbai Ombudsman CentreCase No. : LI-171 of 2006-2007Smt Jayamala RaiV/s.Life Insurance Corporation of IndiaAward Dated : 31.01.2007Shri Rakesh Raman Rai had proposed for three Life Insurance policies under JeevanMitra Triple cover for terms 16,19,21 respectively from Life Insurance Corporation ofIndia, Branch 934 of Thane Divisional Office through proposals dated 11.03.2005 forSum Assured of Rs.2,00,000/- each. Unfortunately, Shri Rakesh Raman Rai was shoton 10.5.2005 at around 11.30 p.m. and died at midnight. When Smt Jayamala Rai , wifeand nominee under the policy preferred a claim to Life Insurance Corporation of India,Kalyan Branch Office of Thane D.O. sent cheques for Rs. 2,00,000 each under eachpolicy stating that LIC decided to settle the claim on ex-gratia basis as the contractwas unconcluded. Not satisfied with this decision, she represented to the Zonal Officeand not receiving any favourable response from them approached this Forum forredressal of her grievance. After perusal of all the records submitted to this Forumparties to the dispute were called for hearing Both documentary and oral evidencesadduced at this Forum have been examined.The complainant submitted copies of theFPR dated 11.5.05 and LIC has also submitted copy of First Premium adjustment sheetdated 11.5.05 and proposal/Review Rating Sheet of the proposals. The point to beexamined in this case is whether there was a concluded contract before the death ofthe Life Assured. In this case, the proposer had submitted all the requirementsincluding deposit towards first premium. He had disclosed all the previous policyparticulars including the lapsed policies. The proposer had informed by his letter dated31 st March/10 th April, 2005 that he was not interested in reviving 3 of his lapsedpolicies. As revival of the lapsed policies was a pre-condition for acceptance of thefresh proposals the Insurer decided to drop the proposals and the decision of LIC wasconveyed to the Proposer. This amounts to a counter proposal by LIC. Though LIC

subsequently accepted the proposals, there is no letter from the Proposer on record toshow that he had accepted the counter proposal of LIC. . The general rule is that thecontract of insurance will be concluded only when the party to whom an offer has beenmade accepts it unconditionally and communicates to the person making the offer.Even in cases where first premium has been sent with the proposal and the insureraccepts the proposal without any modification, assumption of the risk being indicatedby a separate receipt issued for the first premium. But any acceptance is alwayssubject to the condition that any adverse event connected with the risk has occurredbetween the date of proposal and date of acceptance, the assurance is invalid unlessintimation of such event is given to the insurer and acceptance is reapproved. Theacceptance to be complete must be communicated to the proposer, either directly or bysome definite act, such as placing the contract in the mail. Mere delay in giving ananswer cannot be construed as an acceptance, as , prima facie, acceptance must becommunicated to the proposer.It is very clear that the amount paid and kept in deposit towards first premium wasconverted as Premium which is evident from the copy of the premium adjustment sheeton record. The First Premium Receipt, in respect of the policies under dispute wereissued after the death of the life assured on 11.5.2005. The delay in concluding thecontract could be attributed to unwillingness of the proposer to revive all the lapsedpolicies. The proposals were dropped by LIC and perhaps decided to accept the samelater on as per the oral request of the proposer. The premium adjustment was done andconsequently First Premium Receipt was printed and issued after the death of theproposer as the intimation of death had not reached the Insurer. Since the acceptanceof the contract was not communicated to the proposer before his death, there was noconcluded contract. However, LIC has paid claim of Rs. 2 lacs each on ex-gratia basisbased on the merit of the case which seems reasonable. In view of this, there is noreason to interfere with the decision of LIC.Mumbai Ombudsman CentreCase No. : LI-184 of 2005-2006Shri Govindrao Jhatingrao GaikwadV/s.Life Insurance Corporation of IndiaAward Dated : 02.01.2007Shri Dipak Kumar Nivrattirao Sonkamble had taken a Life Insurance policy from UdgirBranch Office of Life Insurance Corporation of India, Aurangabad Divisional Office,under Life Insurance Policy No.982045427 under Plan and Term 75-20 ( Money BackPolicy with profits + Accident Benefit) for sum Assured of Rs.50,000/-.The date ofproposal and the commencement of the policy was 15.02.2001. The said policy lapseddue to non payment of premium from February,2003 and the policy was revived on03.03.2004 based on the Personal Statement regarding health given by ShriDipakkumar Nivrattirao Sonkamble. Shri Dipakkumar Nivrattirao Sonkambleunfortunately expired on 9 th September, 2004, due to Hypertension c Heart disease.When Smt Vijaymali, wife and nominee under the policy, preferred a claim to LifeInsurance Corporation of India, LIC of India, Aurangabad D.O. repudiated the liabilitystating that the deceased life assured had withheld correct information regarding hishealth at the time of revival, and hence, in terms of the policy contract and declarationin the proposal form and personal statement, they were not liable for any paymentunder the policy. In the meanwhile Smt Vijaymali who was suffering from cancer andwas not able to move from her bed gave authority to her father, Shri Govindrao

Jhatingrao Gaikwad to pursue the case but unfortunately she also expired on31.12.2004. Shri Govindrao Jhatingrao Gaikwad made a representation and aggrievedby their decision, Shri Govindrao Jhatingrao Gaikwad approached this Forum forjustice. After perusal of the records parties to the dispute were called for hearing. Theentire records pertaining to the case have been scrutinised. The primary cause ofdeath was Hypertension with Heart Disease and the life assured had no other disease.He has also mentioned that the patient died at home due to heart attack, and he hadnot attended to him earlier and was not treated in any hospital. A bare perusal of themedical certificates would reveal that the leave was obtained on account of someailment like enteric fever, colic pain with severe dehydration/anaemia. There was nohospitalisation nor such ailment was the cause of his death. He died at home due tohypertension with heart disease. Obviously the cause of death had no nexus with thecasual illnesses on the basis of which he secured the leave from the employer. It willnot be out of place to mention that in Government employment/public sector,employees obtain medical certificate many a times falsely, only to secure leave. In thiscase the DLA was working in Government Milk Scheme, Parbani and his wife wassuffering from cancer. Under the circumstances, the suppression of the instant casewas wholly inconsequential having no bearing on the ultimate cause of death of theinsured. The death was sudden due to heart attack at home. LIC repudiated the claimon the basis of the medical certificates submitted by the life assured to his employerfor securing leave. In the claim form ‘B’ he has stated that no other disease precededor co-existed with that which immediately caused death. The medical certificates onwhich LIC relied on to repudiate the claim are not supported by copies of theprescriptions, chemists bills etc. pertaining to the treatment taken by the Life Assured.In view of the above analysis, Life Insurance Corporation of India is hereby directed tosettle the claim under policy No. 982045427 on the life of late Shri Dipak KumarNivrattirao Sonkamble and pay the claim amount as per the terms of the policyconditions to the legal heir of the life assured. The case is disposed of accordingly.Mumbai Ombudsman CentreCase No. : LI-178 of 2006-2007Smt Bebi Namdeo KalbandeV/s.Life Insurance Corporation of IndiaAward Dated : 11.01.2007Shri Namdev Sonaji Kalbande had taken a Life Insurance policy bearing for a SumAssured of Rs.1,00,000/- under Plan and Term (75-20)– a Money Back Policy withProfits and DAB. The commencement of the policy was from 28.02.2005. Unfortunately,Shri Namdev Sonaji Kalbande expired on 25.06.2005 due to CGN/HTN/CRF/ESRD withAnaemia. When Smt Bebi N Kalbande, wife and nominee under the policy, preferred aclaim Life Insurance Corporation of India repudiated the claim stating that thedeceased life assured had withheld material information regarding his health at thetime of effecting the assurance. Not satisfied by the said decision, Smt Bebi NamdevKalbande approached this Forum. After perusal of all the records submitted to thisForum parties to the dispute were called for hearing. The records pertaining to thecase have been examined. As per the Certificate of Hospital Treatment dated 8.9.2005issued by Asst. Professor of Nephrology, S.S.N & P.G.L., Nagpur, Shri NamdeoKalbande was admitted to the hospital on 12.5.2005 (Indoor admission no. 2553) withcomplaints of nausea, loss of appetite, oliguria – 3 months as reported by the patienthimself. The diagnosis arrived at the hospital was CGN/HTN/CRF/ESRD/Anaemia. Inthe Medical Attendant’s Certificate issued by the same doctor, it has been mentioned

that the patient did not die in that hospital. On careful scrutiny of this certificate it isobserved that question no. 5(e) was replied as “7.3.2005 four months” and questionno.7 as “ 7.3.2005.” and the handwriting clearly indicates that this information waswritten subsequently and is not of one and the same person.LIC repudiated the claimon the ground that the life assured had been suffering from CRF, HTN, ESRD andAnaemia before the date of proposal which were not disclosed in the proposal form. Itis observed from the medical papers on record that the life assured consulted medicalman within a month from the inception of the policy and was diagnosed to have ChronicRenal Failure. He was admitted to Medical Post Graduate Institute, Super SpecialityHospital, Nagpur just after two months from the date of proposal with Chronic RenalFailure and End Stage Renal Disease (ESRD) among other complications which clearlypoints to the fact that the invasive progress of the disease could not have developedwithin a month from the date of proposal. However, LIC has not discharged the burdenof proof adequately by providing any proof of treatment before the date of proposal orproved that the life assured had knowledge of the illness, instead they produced theforged hospital records with a view to prove that the life assured was suffering from theillness and was taking treatment prior to the date of proposal. But the Insured was afarmer from a rural area without an easy access to the medical facilities and perhapshe had ignored all the symptoms of the illness in a casual approach and hence notdisclosed in the proposal form.Considering the totality of the case, I am inclined to grant an ex-gratia payment of 50%of the Sum Assured under the policy by invoking power under Rule 18 of the RPGRules, 1998.Mumbai Ombudsman CentreCase No. :LI-187 of 2006-2007Smt Pratidnya Prabhakar GoregaonkarV/s.Life Insurance Corporation of IndiaAward Dated : 25.01.2007Shri Prabhakar Ramchandra Goregaonkar had taken a policy bearing no.923071389from Life Insurance Corporation of India, of Thane Divisional Office through proposaldated 30.01.2004 for a Sum Assured of Rs.30,000/- under Table and Term (91-15)-New Janaraksha Plan with Profits and Accident Benefit. The commencement of thepolicy was from 25.01.2004. Unfortunately, Shri Prabhakar R Goregaonkar expired on14.04.2005 due to Cirrhosis of liver with Ascites and encephalopathy. When SmtPratidnya P Goregaonkar, wife of Late Shri Prabhakar R Goregaonkar preferred a claimunder the above said policy to Life Insurance Corporation of India, Thane DivisionalOffice of Life Insurance Corporation of India repudiated the claim stating that thedeceased life assured had withheld material information regarding his health at thetime of effecting the assurance Not satisfied by the said decision Smt Pratidnya PGoregaonkar appealed to the Zonal Manager and aggrieved by their decision, SmtPratidnya Prabhakar Goregaonkar approached this Forum for redressal of hergrievance. The analysis of the entire records leads to the conclusion that the insuredhad an attack of Chronic Hepatitis with cirrhosis of liver disease with ascites andencephalopathy. The word Ascites means the accumulation of fluid in the peritonealcavity, causing abdominal swelling. Causes include infections such as tuberculosis,heart failure, portal hypertension, cirrhosis and various cancers (particularly of theovary and the liver) and Chronic hepatitis continues for months or years, eventuallyleading to cirrhosis. It may be caused by persistent infection with a hepatitis virus(usually hepatitis B, C or D) which may respond to treatment.Taking all the certificates

into consideration, it would be reasonable to conclude that Shri Goregaonkar had somehealth problems at the time of taking the policy. Since the death has occurred withintwo years LIC has repudiated the claim based on the certificate issued by the MedicalPractitioner. The complainant has also not produced any evidence to prove it otherwiseexcept a correction in the period from 3 years to 3 months in the doctor’s certificate.Such corrections are generally issued on the request of the party after repudiation ofthe claim and cannot be taken as an evidence . The death had occurred within 1 yearand 3 months of taking the policy and the duration of disease as per Doctor’scertificate goes beyond this period. Under the circumstances, the decision of theInsurer seems to be justified.The life assured was a farmer by occupation and perhaps in the absence of goodmedical facilities in remote villages he might not have taken the ailment moreseriously. Moreover, the policy was only for Sum Assured of Rs. 30,000 and underJana Raksha Plan for the benefit of his minor son. Considering the totality of the caseand looking to the socio economic condition of the complainant, an ex-gratia paymentof 50% of the Sum Assured under the policy is granted.Mumbai Ombudsman CentreCase No. : LI-164 of 2006-2007Smt Vishalakshi K ShettyV/s.Bajaj Allianz Life Insurance Company LimitedAward Dated : 31.01.2007Shri Krishna D Shetty had taken a Product Unit Linked policy from Bajaj Allianz LifeInsurance Company Limited under policy no. 0013812998 for Sum Assured ofRs.9,09,160/-. The proposal date was 10.12.2005 whereas the date of commencementof the policy was 28.12.2005. Unfortunately Shri Krishna D Shetty expired on19.04.2006 at home due to Cardio Respiratory Failure. When the nominee,complainant, Smt Vishalakshi Shetty approached the Bajaj Allianz with all thedocuments, Bajaj Allianz Life Insurance Company rejected the claim on the ground thatthe life assured had history of IHD since 4 years with Hypertension, Diabetes Mellitusand hyperlipidemia and was on oral treatment which was not disclosed in the proposalform and diabetic questionnaire. Aggrieved by the said decision of the Company, Smt.Vishalakshi Shetty approached the Office of the Insurance Ombudsman. The records ofthe case were perused and parties to the dispute were called for hearing. Thedocuments submitted by the parties and oral statements made at the hearing havebeen examined. It is noted that the Insurer had taken medical examination report withvarious pathological reports as per their underwriting norms and perhaps based on theclue that the proposer had diabetes, called for PPBS and Diabetes QuestionnaireForm. In the Diabetes Questionnaire Form, the life assured had not disclosed that hewas suffering from diabetes and taking treatment for the same, but on the contraryreplied negatively. The complainant admitted that Dr. Asmita Shah was the familydoctor of the deceased and her husband used to consult Dr. Asmita Shah for anyailment. Dr. Asmita Shah has clearly mentioned in her certificate that the deceasedwas suffering from diabetes for 4-5 years and Hypertension for 3-4 years and thenature of treatment was “Oral hypoglycemia and anti hypertensive”. As regards IHDallegedly suffered by the life assured, Dr. Shah has mentioned that he had chest painon exertion about 15-20 days prior to death and for which he had undergone varioustests like ECG, Blood sugar, lipid profile etc. It is possible that the symptoms of IHDwere observed 15-20 days before his death. The contention of the complainant that

tests done on 3.4.2006 were normal and he was in good health at that time is nottenable in the absence of the referring doctor’s recommendations and the findings.It is clear from the information given by Dr.Asmita N Shah and also the informationgiven by the complainant herself in the statements mentioned above, that the deceasedlife assured was suffering from Diabetes and Hypertension when he proposed forassurance. The complainant in her oral deposition also admitted that her husband hadbeen taking ½ tablet daily for diabetes, on the advice of Dr. Asmita Shah. The lifeassured did not disclose this material information in the proposal form and before theMedical Examiner of the Insurer or in the Diabetes questionnaire Form. Had hedisclosed the correct status of his health at the time of proposal, Insurer would haveprobed further and taken appropriate underwriting decision.Thus the repudiation of death claim by Bajaj Allianz Life Insurance Company on theground of deliberate misstatement and suppression of material facts regarding healthof the life assured at the time of proposal is held sustainable.Mumbai Ombudsman CentreCase No. : LI-033 of 2006-2007Smt Ranjana Anilrao DhandoleV/s.Life Insurance Corporation of IndiaAward Dated : 28.02.2007Shri Anil Daultrao Dhandole had taken a Life Insurance policy bearing no.820882530from Life Insurance Corporation of India, Yavatmal Branch 991 of Amravati DivisionalOffice through proposal dated 26.08.2003.Unfortunately Shri Anil Daultrao Dhandoleexpired on 03.04.2005. The primary cause of death was Ca Penis (operated) and thesecondary cause was secondaries in pleural and lungs, pleural effusion, Septicaemia,multi organ failure. When Smt Ranjana Anilrao Dhandole, wife and nominee under thepolicy, preferred a claim under the above said policy to Life Insurance Corporation ofIndia, Amravati Divisional Office of Life Insurance Corporation of India repudiated theclaim stating that the deceased life assured had withheld material informationregarding his health at the time of effecting the assurance After perusal of all therecords submitted to this Forum parties to the dispute were called for hearing. It isevident from the case papers dated 27.9.2004 of Dr. Ravi Deshmukh that the deceasedlife assured had health problems viz penile growth before he proposed for theinsurance under the above policy for which he had undergone pathological test in 6/03as noted by the doctor. Though the complainant has denied the history of cancer, sheadmitted that the life assured was operated for growth in penis in March, 2003 atKawalkar hospital and again in October, 2004. The fact that he was suffering fromgrowth in penis was further confirmed from the histopathology report dated 2.6.2003submitted by the complainant herself, which ultimately turned out to be cancer leadingto the death of the Life Assured. The analysis of the entire records leads to theconclusion that the Insured had experienced frequent complications for which he hadconsulted medical man and undergone pathological tests and surgery before applyingfor assurance which were not disclosed. In the above case there was clear suppressionof material fact by the deceased life assured and hence LIC’s decision to repudiate theclaim cannot be faulted.In the circumstances, this Forum has no justifiable reason to interfere with the decisionof LIC to repudiate the claim.

Mumbai Ombudsman CentreCase No. : LI-013 of 2006-2007Smt Yogita Pradip PetkuleV/s.Life Insurance Corporation of IndiaAward Dated : 28.02.2007Shri Pradip Shankarrao Petkule had taken two Life Insurance policies bearing nos972954288- Jeevan Surabhi Money Back Policy with Profits and 973087363 -JeevanMitra Triple Cover Endowment Plan with Profits and Accident Benefit from LifeInsurance Corporation of India, Branch Ballarpur of Nagpur Divisional Office for Rs.1,00,000 and 20,000 respectively. Unfortunately, Shri Pradip S Petkule expired on09.03.2004 due to Cardio Respiratory Arrest due to Septicemia shock with Multi OrganFailure. When Smt Yogita Petkule, wife and nominee under the policies preferred aclaim to Life Insurance Corporation of India, LIC of India, Nagpur D.O. repudiated theliability stating that the deceased life assured had withheld correct informationregarding his health at the time of effecting the assurance. Not satisfied with thisdecision, the claimant, Smt Yogita P Petkule made a representation to the ZonalManager of Western Zone of LIC of India for reconsideration of the decision and beingaggrieved at thier decision, Smt Yogita Pradip Petkule approached this Forum. Afterperusal of the records parties to the dispute were called for hearing .The entire recordspertaining to the case have been examined.LIC has not produced any evidence to show that the deceased life assured wassuffering from Acid Peptic disease with jaundice before he proposed for assuranceunder the above mentioned policies except a medical certificate dated nil issued by Dr.P.S.Khekade for the purpose of securing medical leave from 28.11.2000 to 5.12.2000.The only evidence on which LIC relied on was the leave application and medicalcertificate submitted in support of the same in December, 2000 which was before theacceptance of the risk under both the policies. The doctor who had issued thiscertificate in the Special Query Form has mentioned that he was consulted 1 ½ yearsback but he treated him for APD since 6 months only. Thus, LIC has failed to provewith conclusive evidence that the life assured had made deliberate misstatements andwithheld material information at time of effecting the insurance. Normally the employerallow the employee to join the duty back only when the doctor issues a fitnesscertificate. Though in this case such certificate was not produced but it is presumedthat only on fitness the employee was allowed to join duties. The cause of deathmentioned in the death certificate issued by the hospital was septicemic shock withmultiorgan failure in case of left sided pyopneuthorax whereas in the medicalcertificate issued by Dr. Khekade, he had treated him for APD. There is no close nexusbetween the cause of death and the disease mentioned in the medical certificate. Therepudiation of the claim by LIC of India is on the basis of medical certificate issued bythe Doctor for sick leave availed by the Life Assured for a short period i.e. from28.11.2000 to 5.12.2000 which is not supported by any hospitalization records orMedical treatment of the disease. Under the circumstances the said decision of LIC isnot sustainable.

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