1. Death Claim
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1. Death Claim Ahmedabad Ombudsman Centre Case No. LIC / 2 / 116 Smt. Jyoti H. Gurjar Vs. Life Insurance Corporation of India Award Dated 29.10.2003 Death Claim. Shri Harish J.Gurjar took two Policies No.861570599 and 872923186 with date of commencement on 28.5.2000 and 15.12.2001 respectively. He died in October 2002. Respondent treated the Policy No.861570899 null and void under section 45 and withheld their decision for the claim under Policy No.872923186. Hearing held. Respondent, based on the claim form-B and Certificate of Hospital Treatment submitted by the Complainant argued that the DLA was suffering from diabetes and hypertension prior to 3 years of his death and this fact was not disclosed by the DLA. The Respondent could not produce the treatment papers of diabetes and hypertension to corroborate the past h/ o these diseases of the DLA as asked for by this office. However, they counter- argued vide their letter dated 9.1.03 that since the Complainant herself submitted the Form-B and Certificate of Hospital Treatments obtained by her, she was aware of the statements made by the doctors and if she had any objection as to the fact of the statements she should have protested and corrected it. The Respondent submitted that they have decided to pay ex-gratia payment to the Complainant against the claim under Policy No.872923186 in view of single premium Policy. It is observed from the Medical Attendant’s Certificate in claim Form-B and certificate of hospital treatment submitted by the Complainant that the DLA was known case of diabetes mellitus and hypertension for 3 years prior to the date of his death. Repudiation of claim under Policy No.861570599 upheld. Since the Respondent offered Rs.29,913/- on ex-gratia basis under Policy No.872923156 the same is not discussed. Ahmedabad Ombudsman Centre Case No. LIC / 2 / 116 Smt. Jyoti H. Gurjar Vs. Life Insurance Corporation of India Award Dated 29.10.2003 Death Claim. Shri Harish J.Gurjar took two Policies No.861570599 and 872923186 with date of commencement on 28.5.2000 and 15.12.2001 respectively. He died in October 2002. Respondent treated the Policy No.861570899 null and void under section 45 and withheld their decision for the claim under Policy No.872923186. Hearing held. Respondent, based on the claim form-B and Certificate of Hospital Treatment submitted by the Complainant argued that the DLA was suffering from diabetes and hypertension prior to 3 years of his death and this fact was not disclosed by the DLA. The Respondent could not produce the treatment papers of diabetes and hypertension to corroborate the past h/ o these diseases of the DLA as asked for by this office. However, they counter-argued vide their letter dated 9.1.03 that since the Complainant herself submitted the Form-B and Certificate of Hospital Treatments obtained by her, she was aware of the statements made by the doctors and if she had any objection as to the fact of the statements she should have protested and corrected it. The Respondent submitted that they have decided to pay ex-gratia payment to the Complainant against the claim under Policy No.872923186 in view of single premium Policy. It is observed from the Medical Attendant’s Certificate in claim Form-B and certificate of hospital treatment submitted by the Complainant that the DLA was known case of diabetes mellitus and hypertension for 3 years prior to the date of his death. Repudiation of claim under Policy No.861570599 upheld. Since the Respondent offered Rs.29,913/- on ex-gratia basis under Policy No.872923156 the same is not discussed. Ahmedabad Ombudsman Centre Case No. LIC / 2 / 124 A. U. Makwana Vs. Life Insurance Corporation of India Award Dated 31.10.2003 Policy No. : 811636810/11 Repudiation of death claim. Complainant is the husband of DLA Smt. J. A. Makwana. DLA had taken 2 Policies for S. A. of Rs.50,000/- each. Both Policies commenced on 8.6.2001 and she died on 7.8.2001 i.e. within 2 months. Respondent investigated the case. Investigation revealed that the DLA was a cancer patient and had undergone treatment for throat cancer prior to taking the insurance Polices. Documents on record were sufficient to decide the case. Therefore, hearing not held. It is observed from the documents the Laryngoscopy and biopsy were done on the DLA on 16.4.2001 and diagnosed the disease as throat cancer. This fact was wilfully suppressed by the DLA while proposing for the Policies. Repudiation upheld and dismissed the case without any relief. Ahmedabad Ombudsman Centre Case No. LIC / 2 / 131 Smt. B. K. Mewada Vs. Life Insurance Corporation of India Award Dated 24.11.2003 Policy No. : 812132303 Repudiation of death claim - Complainant, wife of the DLA. DLA died within a period of 1 year. Being an early claim, Respondent investigated the claim and found that the DLA had been suffering from DM and HT prior to his proposal for insurance. Certificate of Hospital Treatment also confirmed this fact. The h/o the DLA’s disease was reported by the Complainant himself to the hospital authorities. The fact of his diseases was not disclosed by him while proposing for the insurance. It is observed that the DLA had been suffering from these diseases and he had not disclosed the fact of his existing disease thereby breached the utmost good faith. The Respondent’s decision to invoke section 45 of the I.A 1938 to treat the Policy null and void upheld. Complaint dismissed without any relief. Ahmedabad Ombudsman Centre Case No. LIC / 2 / 117 Smt. S. H. Patanwadia Vs. Life Insurance Corporation of India Award Dated 28.11.2003 Policy No. : 872834196 Repudiation of death claim - Policy commenced on 28.1.2002 - LA died on 13.7.2002. Complainant argued that the Respondent’s approved doctor had examined the DLA before he proposed for insurance. She further contended that the DLA’s disease was cured before taking the Policy and therefore he might not have disclosed the fact of his existing disease and he treatments taken hereof. It is observed from the documents such as COT, MAC that the DLA had been suffering from Pulmonary Koch’s as well as Alcoholic Chirrosis long back and these facts were not disclosed. Repudiation upheld. Ahmedabad Ombudsman Centre Case No. LIC / 2 / 138 Smt. V. S. Upadhyay Vs. Life Insurance Corporation of India Award Dated 11.12.2003 Policy No. : 872859355/872860467 Death claims - Complainant wife of DLA - DLA had two Policies, one for S.A. of Rs.50,000/- and another for S. A. of Rs.25000/- commenced on 15.9.2000 and 11.1.2001 respectively. DLA died on 6.2.2003 due to heart attack. Claim investigated and found that the DLA was suffering from Myocardial Infarction prior to commencement of the Polices. Documents were sufficient to decide the case. Hence, no personal hearing of parties held. It is observed that the DLA was suffering from myocardial infarction and had availed leave from his employer for a long period prior to the commencement of the Policies, the fact of which was not disclosed by him. Repudiation upheld. Ahmedabad Ombudsman Centre Case No. LIC / 2 / 123 Smt. Mukesh P. Khiani Vs. Life Insurance Corporation of India Award Dated 18.12.2003 Policy No. : 813857869 Death claim - S.A.Rs.1,00,000/- Policy commenced in July 2001 - LA died in February 2003 due to heart attack. Claim investigated. Investigation revealed that DLA was suffering from Ischemic Heart Disease prior to the proposal for insurance. Complainant submitted that the age of the DLA was 64 years and apart from routine medical report, ECG, BST & SPQ 001 reports were also submitted to the Respondent and accordingly, they granted the insurance on ordinary rate. He argued that if there had been any heart attack it would have reflected in the special tests like ECG, BST & SPQ 001. He denied the DLA’s Ischemic Heart Disease before taking the Policy. Respondent argued that as per the COT given by a doctor, the DLA was suffering from Ischemic heart disease and had taken treatment for 48 hours, probably in January 2001. It is observed from the ECG Report that the DLA had “left ventricular hypertrophy” problem and clearly knowing this fact the Respondent granted the insurance on “ordinary rate” which indicates that the Respondent was satisfied with all aspects of the proposal. It is further observed that the doctor gave the COT without referring to any case papers, but purely from the memory. It is surprsing how the doctor could remember the exact diagnosis, treatments and medicines administered to the DLA even after two years, particularly when no case papers were available with the Hospital. Repudiation set aside. Directed the Respondent to pay the full SA with accrued bonus, if any. 8% simple interest also allowed on the admissible amount. Ahmedabad Ombudsman Centre Case No. LIC / 2 / 140 Smt. H. K. Kathia Vs. Life Insurance Corporation of India Award Dated 18.12.2003 Policy No. : 812736699 Death claim - Policy commenced in April 2002 - S.A Rs.50,000/-.LA died in January 2003. From the various certificates and documents on record, it is observed that the DLA was on sick leave for 61 days from 1.12.2000 to 9.2.2001. He was also treated for his paralytic attack as an indoor patient from 6.12.2000 to 10.12.2000. The above facts have been confirmed by the Complainant herself in her letter to the Claim Review Committee.