PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE …

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF KARNATAKA (UNDER RULE NO: 16/17 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – NEERJA SHAH In the Matter of Mrs GEETABAI /s LIC OFINDIA

Complaint No: BNG-L-029-1920-0613 Award No: IO/BNG/A/LI/0432/2019-2020

1. The Complainant’s husband availed life insurance policy number 661825991 from Respondent

Insurer (hereinafter referred as RI).

2. The Complainant being the nominee of the policy submitted documents for Death claim payment to

RI on 30.12.2017. Death Claim payment was repudiated vide letter dated 21.06.2019. The

Complainant has submitted representation to RI on 05.07.2019 for payment of death claim.

3. Aggrieved with the non-settlement of death claim payment by RI, the Complainant approached this

Forum. The complaint was initiated for further process and the case was posted for hearing on

18.03.2020.

4. RI Communicated to the Forum vide email dated 07.02.2020 that they have settled the matter

amicably by paying an amount of ₹.3,11,430/- including the penal interest for delay to the

Complainant via NEFT to her Pragathi Krishna Gramin Bank account on 06.02.2020

5. The Complainant had communicated to the Forum vide letter dated 19.02.2020 that she received

the death claim amount from RI and requested for withdrawal of complaint.

6. As the Complainant requested for withdrawal of the case and the same is settled by the RI, Case is

being treated as closed and disposed of.

Dated at Bengaluru on 25th February, 2020

(NEERJA SHAH) INSURANCE OMBUDSMAN

FOR THE STATE OF KARNATAKA

PROCEEDINGS BEFORE - THE INSURANCE OMBUDSMAN, STATE OF M.P. &

C.G.

(UNDER RULE NO: 16(1)/17 OF THE INSURANCE OMBUDSMAN RULE 2017)

Ms Shashi Binjwa ..……..……………………………………….. Complainant

V/S

Future Generali India Life Ins Co.Ltd .……….........................……Respondent

COMPLAINT NO: BHP-L-017-1920-0408 ORDER NO: IO/BHP/A/LI/0273 /2019-2020

1. Name & Address of the

Complainant

Ms Shashi Binjwa

RH-107, Slice 1, Sector A

Scheme NO.78, Vijay Nagar, Indore

2. Policy No:

Type of Policy

G14000001

Future Generali Group Term Life Insurance

Ms.Shashi Binjwa (Complainant) being nominee has filed a complaint against Future

Generali India Life Insurance Company Ltd (Respondent) alleging non payment of full

Death claim.

Brief facts of the Case - The complainant has stated that her husband had taken above

Group Insurance policy through Bajaj Finance with membership No. 49876600 for a sum

insured of Rs.3,50,000/- and her husband expired on 20.09.2018. Thereafter she had

lodged death claim of her husband vide Claim No.C0002265 in April 2019 with the

respondent company. But respondent company had made payment of Rs.2,831/- in place

of Rs.3,50,000/- to which she is not satisfied. She had also written to the respondent

company vide email dated 25.07.2019 to which she has not got any response so far. She

has approached this forum for redressal of her grievance.

The respondent in their SCN have stated that the above policy was issued to the

Bajaj Finance Ltd in which Mr Jagdish Binjwa was insured member with the date of

commencement of 22.09.2017 for a base sum assured of Rs.3,50,000/-. Life insured

expired on 21.09.2018. Complainant who is nominee under the policy has submitted

death claim on 16.09.2019. DLA died due to consumption of celphos poison. FIR filed

under Sec 174 clearly states that DLA died due to consumption of celphos poison and

postmortem report clearly mentions the cause of death as due to cardio respiratory failure

Duration of policy/Policy period 22.09.2017

3. Name of the insured

Name of the policyholder

Mr Jagdish Binjwa

Bajaj Finance Ltd

4. Name of the insurer Future Generali India Life Insurance

Company Limited

5. Date of Repudiation/ Rejection --

6. Reason for Repudiation/

Rejection

--

7. Date of receipt of the Complaint

8. Nature of complaint Non payment of full death claim

9. Amount of Claim --

10. Date of Partial Settlement 30.09.2019

11. Amount of relief sought Rs.3,50,000/-

12. Complaint registered under Rule Rule No. 13(1)(b) Ins. Ombudsman Rule

2017

13. Date of hearing/place 13.02.2020 at Bhopal

14. Representation at the hearing

For the Complainant Ms. Shashi Binjwa

For the insurer Mr. Sanjay Swarnkar, Dy. Manager

15. Complaint how disposed Dismissed

16. Date of Award/Order 13.02.2020

as a result of consumption of poison. Certificate of Insurance clearly states that if an

insured member commits suicide whether sane or insane within 12 months from the cover

commencement date, the nominee will receive 80% of the premium paid in respect of the

insured member and therefore respondent settled the claim amount by paying 80% of the

premium amount of Rs. 2831/- which was credited in her account on 30.09.2019.

The complainant has filed complaint letter, Annex. VI A and correspondence with

respondent, while respondent have filed SCN with enclosures.

I have heard both the parties at length and perused papers filed on behalf of the

complainant as well as the Insurance Company.

A group policy bearing no. GM000001 was issued to Bajaj Finance Limited in which

DLA Jagdish Binjwa was a member with risk commencement date as 22.09.2017 and

cover ends on 21.09.2018. As per complainant DLA expired on 20.09.2018 and after

expiry of DLA his wife has filed a claim as a nominee in which she received a sum of Rs.

2831/- on 30.09.2019. The representative of respondent has stated that respondent

received a death claim on 16.09.2019 intimating that the LA passed away on 21.09.2018.

He further stated that DLA had committed suicide and died due to consumption of

Celphos Poison, hence respondent has settled the claim as per exclusion clause 1 and paid

80% of the premium amount. Medical records of Bombay Hospital, Indore dated

20.09.2018 shows that insured was admitted with complaint of ingestion of celphos

tablet. Medical certificate with respect to cause of death issued on form no. 4 also shows

the cause of death as celphos poison. Exclusion clause no. 1 of policy deals with suicide

clause which states that incase the insured member commits suicide whether sane or

insane within 12 months from the cover commencement date, the nominee will receive at

80% of the premium paid in respect of the insured member. Death certificate shows date

of death as 21.09.2018 and policy was effective from 22.09.2017 to 21.09.2018. Hence as

per above clause of policy, respondent had rightly settled/paid the claim and acted in

accordance with the terms and conditions of the policy. In the result complaint is liable to

be dismissed.

The complaint filed by Ms. Shashi Binjwa stands dismissed herewith.

Let copies of Award be given to both the parties.

Dated : Feb 13, 2020 (G.S.Shrivastava)

Place : Bhopal Insurance Ombudsman

Mrs Chitrarekha Bhade ..……..……………………………………….. Complainant

V/s

SBI Life Insurance Co. Ltd ………..……….........................……Respondent

COMPLAINT NO: BHP-L-041-1920-0386 ORDER NO: IO/BHP/A/LI/0281/2019-2020

Mrs Chitrarekha Bhade (Complainant) being nominee has filed a complaint against SBI

Life Insurance Company Ltd (Respondent) alleging repudiation of Death claim of her

husband.

Brief facts of the Case - The complainant has stated that she is wife of the life insured

and resident of Chhindwara. Her husband had taken the above policy and when the

premium was due in the policy on 19.06.2018 her husband had suffered brain hemorrhage

for which he was under treatment from 06.06.2018 to 21.09.2018. During this period he

was under coma, as a result of which he could not deposit the premium under the policy.

As premiums were not paid respondent had rejected the death claim of her husband. She


Complainant

Mrs Chitrarekha Bhade

At Post Kamthi Chhindwara

Chhindwara M.P.

2. Policy No:

Type of Policy

Duration of policy/Policy period

1n491661704

SBI Life – Smart Money Back Gold

19.06.2017



Mr Vitthal Rao Bhade

Mr Vitthal Rao Bhade

4. Name of the insurer SBI Life Insurance Company Limited

5. Date of Repudiation/ Rejection 10.12.2018

6. Reason for Repudiation/ Rejection As policy was in lapsed condition hence Sum

assured not payable

7. Date of receipt of the Complaint 05.11.2019

8. Nature of complaint Non payment of death claim


10. Date of Partial Settlement --


12. Complaint registered under Rule Rule No. 13(1)(b) Ins. Ombudsman Rule 2017



For the Complainant Absent

For the insurer Mr Pankaj Vashistha, CRM-Head



had represented to the Head Claims of respondent at Mumbai office but has not got any

response from them also. She has therefore approached this forum for redressal of her

grievance.

The respondent in their SCN have stated that the above policy was issued to DLA

with date of commencement as 19.06.2017 for a Sum assured of Rs.3 lac and premium

paying term of 12 years. Company had received only initial premium under the policy and

renewal premium due on 19.06.2018 was not received by the company and therefore

policy lapsed w.e.f. 19.06.2018. Policy holder died on 25.07.2018 and on the date of

death, policy was in lapsed status. Policy did not acquire any paid up value under the

policy and hence nothing is payable. Company had received duly filled and signed

mandate dated 05.07.2017 for auto debit of renewal premium for the period 19.06.2018 to

19.06.2029. However premium due on 19.06.2018 could not be honoured through auto

debit due to reason insufficient balance and the same was intimated to policyholder vide

letter dated 24.06.2018. As per bank statement received by the company, it is clear that the

deceased did not have sufficient balance in his account on the due date of renewal

premium. As a service gesture, company sent renewal premium intimation dated

05.05.2018 and lapse intimation dated 19.07.2019. DLA died on 25.07.2018 and claim

intimation was received by the company and the policy was in lapsed status on the date of

death. As per policy terms, policy will acquire paid up value if atleast 3 full policy

premiums have been paid. But in the instant case premium due on 19.06.2018 was not

paid by the complainant and therefore policy had not acquired any paid up value and thus

nothing is payable.

The complainant has filed complaint letter, Annex. VI A and correspondence with


During hearing complainant remained absent. I have heard the representative of the

respondent company and perused papers filed on behalf of the complainant as well as the

Insurance Company.

SBI Life Smart Money Back Gold Policy No.1N491661704 was issued to the DLA with

date of commencement as 19.06.2017 for a basic sum assured of Rs.3 lacs with premium

of Rs.34,848/- payable yearly. DLA died on 25.07.2018 and after the death, claim was

lodged by the complainant / DLA’s wife which was repudiated by the respondent on

10.12.2018 stating that nothing is payable, as the policy was in lapsed status on the date of

death of DLA. As per SCN, policy was issued on 19.06.2017, only initial premium under

the policy was received and renewal premium due on 19.06.2018 was not received by the

respondent hence policy was lapsed w.e.f. 19.06.2018. They further stated that DLA died

on 25.07.2018 and as on date of death the policy was in lapsed status and did not acquire

any paid up value hence nothing is payable. The representative of the respondent during

hearing has stated that renewal premium under the policy were payable on 19th June every

year and a signed mandate dated 05.07.2017 for auto debit of renewal premium for the

period from 19.06.2018 to 19.06.2029 was received by the respondent which could not be

honoured on 19.06.2018 i.e. on premium due date through auto debit due to the reason of

insufficient balance. Policyholder was intimated the same on 24.06.2018. He further stated

that as a service gesture, company sent renewal premium intimation dated 05.05.2018 and

lapse intimation dated 19.07.2019. Respondent has filed ECS mandate dated 05.07.2017

and photocopy of statement of account of the DLA showing insufficient balance as on

19.06.2018. The representative of respondent has also stated that mandate was not

honoured as there was insufficient balance in the bank account of DLA. Respondent has

also filed a letter dated 24.06.2018 sent to the DLA in which it is mentioned that mandate

was not honoured due to insufficient balance. In complaint also, complainant had accepted

that as the DLA was in coma hence premium could not be deposited. During hearing none

appeared on behalf of the complainant to press the complaint. Under above circumstances,

repudiation of claim by respondent is justified and is in accordance with the terms and

conditions of the policy. In the result, complaint is liable to be dismissed.

The complaint filed by Mrs Chitrarekha Bhade stands dismissed herewith.

Let copies of the order be given to both the parties.



Mrs Rekha Rajak ..…………………………………….…………….. Complainant

V/s

Life Insurance Corporation of India ……..……….........................……Respondent

COMPLAINT NO: BHP-L-029-1920-0472 ORDER NO: IO/BHP/A/LI/ 0291 /2019-

2020


Complainant

Mrs Rekha Rajak

W/o Late Shri Munnalal Rajak

H No 20, Near H E Stores, Opposite

Hanuman Mandir, Harshwadan Nagar,

T T Nagar, Bhopal

2. Policy No: 205274528

Mrs Rekha Rajak (Complainant) has filed a complaint against Life Insurance Corporation

of India (Respondent) alleging repudiation of Death claim of her husband.

Brief facts of the Case - The complainant has stated that her husband had taken above

policy from the respondent company and premiums under the policy were regularly paid

by him. She had submitted death claim of her husband which has been rejected by the

respondent. She has approached this forum for redressal of her grievance.

The respondent in their SCN have stated that the above policy was issued to the

DLA with the date of commencement of 28.04.2016 for a sum assured of Rs.6,00,000/-

under Table 822-17. Policy holder / life assured died on 26.03.2018 and death claim was

rejected as DLA was suffering from Brain Tumour and got operated on 30.03.2016 which

is prior to date of proposal i.e. 31.03.2017 but the same was not disclosed in proposal.

Repudiation letter was sent to nominee on 14.03.2019.

19. The complainant has filed complaint letter, Annex. VI A and correspondence with


20. During hearing complainant remained absent. I have heard the representative of the

respondent company at length and perused papers filed on behalf of the complainant as

well as the Insurance Company.

21. Policy No.205274528 was issued on the life of the DLA under Plan 822-17 with risk

commencement date of 31.03.2017. After the death of DLA on 26.03.2018, complainant

Type of Policy


LIC’s Anmol Jeevan -2

28.04.2016



Mr Munna Lal Rajak

Mr Munna Lal Rajak

4. Name of the insurer Life Insurance Corporation of India

5. Date of Repudiation/ Rejection 14.03.2019

6. Reason for Repudiation/ Rejection Non Disclosure of material facts at the time of

inception of policy


8. Nature of complaint Rejection of death claim




12. Complaint registered under Rule Rule No. 13(1)(b) Ins. Ombudsman Rule 2017




For the insurer Mr K P Nayak, A.O.



lodged death claim which was repudiated by the respondent stating that the DLA was

suffering from brain tumour prior to the signing of proposal form and not disclosed

material facts related to health. Representative of the respondent has argued that deceased

was suffering from brain tumour (Oligodendroglioma) and got operated on 30.03.2016

which is prior to the date of proposal i.e. 31.03.2017 and the same was not disclosed in the

proposal form. Respondent has filed indoor case papers of Jawaharlal Nehru Cancer

Hospital and Research Centre, Bhopal wherein insured was diagnosed with

Oligodendroglioma. In these papers it is mentioned that patient is a post operated case of

Oligodendroglioma and cranioblastoma excision was done on 30.03.2016. In clinical

history of above hospital also it is mentioned exploratory RT frontoparital craniotomy

along with tumour excision on 30.03.2016 at HH, Bhopal. These medical records reveal

that DLA was suffering from brain tumour for which he underwent operation on

30.03.2016. Proposal form was signed and filled up on 31.03.2017 in which DLA had

denied of having undergone any treatment / operation and ailment of brain. Hence DLA

was suffering from the ailment of brain tumour prior to the proposal date and pre-existing

ailment was not disclosed by the DLA at the time of signing the proposal form and

suppressed material facts. In the result, respondent has rightly repudiated the claim and

acted in accordance with the terms and conditions of the policy and complaint is liable to

be dismissed.

22. The complaint filed by Mrs Rekha Rajak stands dismissed herewith.

23. Let copies of the order be given to both the parties.



17) Brief Facts of the Case: Mrs Y Durga Devi filed a complaint stating that the insurer LIC of India had repudiated death claim on the policy of her husband. Death claim was not settled by the insurer alleging that there was one gap in the premiums paid through Salary Savings Scheme. As her appeal to the Claims Review Committee of the insurer was also refused, the

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

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

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

Case between: Mrs. Y Durga Devi ………..The Complainant Vs

M/s LIC of India, Rajahmundry Division …………The Respondent Complaint Ref. No. HYD-L-029-1920-0704 Award No. : I.O./HYD/A/LI/0300 /2019-20

1. Name & address of the complainant Mrs. Y Durga Devi Door no. 1-277/1 A, OC Colony Krishnavaram Village,Kirlampudi Manda East Godavari dist,Amalapuram, Andhra Pradesh 533435

2. Policy No./Collection No.

Type of Policy

Duration of Policy/Policy period

801955325 28.12.2015 814-12 SA 5 Lakhs

3. Name of the insured & Policy Holder Late Mr. Y Srinivas 4. Name of the insurer M/s LIC of India, Rajahmundry Division

5. Date of Repudiation 18.9.2018

6. Reason for repudiation Policy lapsed due to one gap ,nothing payable


8. Nature of complaint Repudiation of death claim

9. Amount of Claim Rs.5, 00, 000/-

10. Date of Partial Settlement Nil

11. Amount of Relief sought Rs. 5, 00, 000/-

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

Insurance Ombudsman Rules, 2017

Any partial or total repudiation of claims by the life

insurer, general insurer or the health insurer.

13. Date of hearing/place 19.02.2020/Hyderabad


a) For the complainant Absent

b) For the insurer Mr.T Ratna Babu AO

15. Complaint how disposed Allowed

16. Date of Order/Award 20.2.2019

complainant approached this forum. Insurer stated that since premiums due 4/2016 was unpaid, as per terms and condition of the policy, it is in lapsed condition hence nothing is payable. The complaint fell within the scope of the Insurance Ombudsman Rules 2017 and so it was registered. Hence the complaint.

18) Cause of Complaint:

a) Complainants argument: In her complaint letter dated 27.12.2019, the complainant stated

that her husband took the LIC policy 801955325 with DOC 28.12.2015 for Sum Rs.500000/- on

his life .Premium for first two months from 12/2015 to 1/2016 has been paid in person at the

time of proposal under S.S.S. mode. She received letter from LIC stating that nothing is payable

under the policy as the policy is in, lapsed condition due to one gap i.e. 4/2016. Recovery of

premium was regular till death. Therefore, the complainant pleaded for intervention of this

forum for settlement of the claim.

b) Insurer’s argument: In its self contained note dated 30.12.2019, the insurer submitted that

the death claim intimation was received under the policy .Policy was in lapsed condition on the

date of death with one gap 4/2016 and policy had not accrued any paid up value hence nothing

is payable as per rules. As per latest instructions from Central Office case is under

reconsideration at DO DRC .

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

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

insurer.

20) The following documents were placed for perusal

a) SCN dt. 13.1.2020.

b) Complaint letter dated: 27.12.2019

c) Repudiation letter dt. 18.9.2018

d) Copies of Policy Schedule & Proposal.

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

Pursuant to the notices issued by this office, complainant has expressed her inability to

attend the hearing at Hyderabad, representative of the insurer attended the hearing held at

Hyderabad on 19.02.2020.

During the course of personal hearing, the representative of the insurer, who attended the

hearing, informed the forum that the claim was admitted on 15 .2.2020 for Rs. 532188/- in

DO DRC as per the new circular CO/CRM/1184/23 dated 16 December 2019.

On a careful consideration of the written submissions of both the parties and the

documentary evidence adduced, it is observed that as per the new circular CO/CRM/1184/23

dated 16th December 2019, death claims under policies issued w.e.f 1.1.2014 will be

considered on ex-gratia if there are only 1 or 2 initial gaps and where the total gaps including

initial gaps does not exceed 3 gaps by Divisional office referring the case to DODRC on ex-gratia

basis. In the above case there was one gap . As per the letter from Rajamahendravaram Urban

police, salary deduction letter was received by them in May 2016 from LIC, due to delay in

receiving the deduction letter premium was deducted from May 2016. Insurer has admitted

the claim on 152.2020 for sum Rs. 532188/-. In view of the above it is treated as allowed.

Hence the complaint is treated as allowed.

AWARD

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

the parties, the complaint is treated as closed.

In result, the complaint is allowed.

22) The attention of the Insurer is hereby invited to the following provisions of Insurance

Ombudsman Rules, 2017:

a) According to Rule 17(6) the insurer shall comply with the award within 30 days of the receipt

of the award and intimate compliance to the same to the Ombudsman.

b) According to Rule 17(7) the complainant shall be entitled to such interest at a rate per

annum as specified in the regulations, framed under the Insurance Regulatory &

Development Authority of India Act from the date the claim ought to have been settled

under the Regulations till the date of payment of the amount awarded by the Ombudsman.

c) According to Rule 17 (8) the award of Insurance Ombudsman shall be binding on the

Insurers.

Dated at Hyderabad on the 20th day of February 2020

I.SURESH BABU)

INSURANCE OMBUDSMAN

FOR THE STATES OF A.P.

TELANGANA AND CITY OF YANAM


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

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

Case between: Smt P Usha………..The Complainant Vs

M/s LIC of India ( Rajahmundry) …………The Respondent Complaint Ref. No. HYD-L-029-1920-650,651,652,653

Award No. : I.O./HYD/A/LI/0301,0302,0303,0304 /2019-20 1. Name & address of the complainant Smt P Usha

W/o Late P Addula Rao D.No. 8-7-3,11 th Ward ,Near water tank, Ropram Street ,Narasapuram , W .G.Dt., Pin code -534275

2. Policy No./Collection No. Type of Policy Sum Assured DOC Premium, Mode

806413308, 806430859, 806435894, 806439041 827-20 814-19 836-21 836-21 125000 100000 200000 200000 27.9.2014 14.5.2016 28.11.2017 31.3.2017 Rs.5119 Yrly Rs.6196 Yrly Rs.6114 Hly Rs.6114 Hly

3. Name of the insured & Policyholder Late Sri. P Addula Rao

4. Name of the insurer M/s LIC of India (Rajahmundry Division)


6. Reason for repudiation Suppression of previous ill health



9. Amount of Claim Rs.625000/- total amount on 4 policies


11. Amount of Relief sought Claim Amount

12. Complaint registered under Rule No.13 (b) of Insurance Ombudsman Rules, 2017

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

13. Date of hearing/place 19.2.2020/ Hyderabad

14 Representation at the hearing

a) For the complainant Smt P Usha

b) For the insurer Mr. T Ratana Babu AO


16. Date of Order/Award 20.2.2020

17) Brief Facts of the Case: Smt P Usha filed a complaint stating that the insurer M/s LIC of

India had repudiated death claim preferred by her on four policies of her husband on his death.

Insurer had refunded the premium on four policies. Later claim on policy 806413308 was

settled for Rs. 109643/- instead of Rs.125000/-. Insurer M/s LIC of India stated that claim on

three policies was repudiated due to suppression of material facts.

Hence the complaint.


a) Complainant’s argument: In her complaint letter dt. 18.12.2019 the complainant stated that her husband’s expired on 26.6.2017 at government general hospital Kakinada. He had taken four LIC Policies. Claim on one policy is settled. LIC had rejected the claim on other three policies. Claim was rejected stating that her husband was chronic alcoholic, hypertension from 2 years, diabetic for 10 years and suffering from chronic kidney disease since 2010 and underwent dialysis in 2012. Claimant has approached Central Office Claims Redressal Committee, but the committee upheld the decision of the Division to repudiate the claim. Therefore, the complainant pleaded for intervention of this forum for settlement of her claim by the insurer. b) Insurer’s argument: In its self contained note dated 6.1.2020, the insurer LIC of India submitted that they received the death claim intimation on the policies 1)806413308 2)806430859 3)806439041 4)806435894. The insurer submitted that since the suppression of material facts by the insured had a bearing on their assessment of risk, the claim had been repudiated as per policy terms and conditions. The same was upheld by Zonal authorities. Since 3 years elapsed from the date of issuance on policy 806413308 claims was settled on 21.3.2019. Under other three policies premium was refunded as per the provisions of section 45 of insurance act 2015. The contention of the claimant that admission of one policy and rejection of other three policies is not correct and not tenable as all four policies are different policy contracts and taken with different date of commencement .Therefore the insurer pleaded for dismissal of the complaint by this forum.

19) Reason for Registration of Complaint:- Scope of the Insurance Ombudsman Rules-2017: Any partial or total repudiation of claims by the life insurer, general insurer or the health insurer.

20) The following documents were placed for perusal. a) SCN dt.06.01.2020 b) Complaint letter dated 18.12.2019 c) Repudiation letter dt.22.10.2018 d) Copies of Policy Schedule & Proposal.

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

Pursuant to the notices issued by this office, the complainant and representative from

insurer attended the hearing held at Hyderabad on 19.2.2020.

During the hearing the complainant repeated the contentions of the complaint. On the

other hand, the representative of the insurer who attended the hearing argued that the

deceased life assured had suppressed material information about his health condition at the

time of proposal.

On careful consideration of the written and oral submissions of both the parties and the documentary evidence adduced, it is observed that the deceased life assured had undergone treatment prior to the date of proposal, he was diagnosed with chronic Kidney disease, underwent Dialysis on 2.1.2012, 5.1.2012 and 8.1.2012, he was known case of DM for 10 years, HNT for 2 years and past history of CKD for two years, he was alcoholic and smoker as per the case sheet of Govt. General hospital Kakinada. Serum creatinine level was 13.9 gm which

means that his kidneys were not working well. He was suffering from Chronic kidney disease CHD and was on maintenance hemodialysis( MHD). On tablets Sevelamer 400 MG which is used to lower high blood phosphorus (phosphate) levels in patients who are on dialysis due to severe kidney disease ,Tablet glucomet fort E for type 2 diabetes mellitus, Amlodipine for high blood pressure. As per the OP details of Arogyasri he had taken treatment at KIMs Rajahmundry and GGH Kakinada on several occasions since 12.5.2010. He was treated every month from April 2016 to January 2017 in Government hospital Kakinada in nephrology department. On policy 806435894 premium due 5/2017 was paid on 27.6.2017 which is after the death of life assured on 26.6.2017. The insurer had produced the case sheets as proof of DLA treatment for the said diseases which were prior to commencement of polices. The DLA knowing well about his health conditions, choose not to disclose these material facts with a fraudulent intention while taking the policy. Had the DLA disclosed the said material information about his health and about pervious policies it would have affected the underwriting requirements. DLA had taken new policies without disclosing about pervious policy details with fraudulent intentions. Had the policyholder disclosed the risk on the life for additional risk cover, insurer could have considered under revised terms and condition by obtaining special reports. This lead to underwriting the proposal without calling for special. In the proposal form under Question 10 A details of previous insurance taken during the last 3 years giving full details is called for, where DLA has written NIL. Insurer had repudiated claim on all the four policies and refunded the premium to complainant on 6.11.2018. However with reference to Circular CO/CRM/1140/23/dated 24.10.2018, claim reported after three years from date of commencement of risk, policy cannot be questioned on grounds of fraud or suppression of material facts case hence case was reopened on policy no. 806413308 as duration was more than three years from DOC to date of representation. Insurer had reconsidered the claim and was settled on 21.3.2019 for Rs.109643/- and premium paid was refunded on 6.11.2018 Rs.15357/- Total Rs.125000/-).On the other three policies, the premium paid was refunded on 8.11.2018 as duration was less than three years and suppression of material fact was proved.

The Forum comes to the conclusion that there was suppression of material facts at the time of obtaining the said policy and hence the insurer is justified in repudiating the death claim on three policies and settling the claim on policy 806413308 for full Sum assured. Insurer does not warrant any intervention. Hence, the complaint is treated as dismissed.

AWARD Taking into account the facts & circumstances of the case and the submissions made by both the parties during the course of the hearing, the repudiation decision taken by the insurer is in consonance with the policy terms and conditions and doesn’t warrant the intervention of this forum. In result, the complaint is dismissed.

22) The attention of the Insurer is hereby invited to the following provisions of Insurance

Ombudsman Rules, 2017:

d) According to Rule 17(6) the insurer shall comply with the award within 30 days of the receipt of the award and intimate compliance to the same to the Ombudsman.

e) According to Rule 17(7) the complainant shall be entitled to such interest at a rate per annum as specified in the regulations, framed under the Insurance Regulatory & Development Authority of India Act from the date the claim ought to have been settled under the Regulations till the date of payment of the amount awarded by the Ombudsman.

f) According to Rule 17 (8) the award of Insurance Ombudsman shall be binding on the Insurers.


(I.Suresh Babu)

INSURANCE OMBUDSMAN FOR THE STATES OF A.P.



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

OMBUDSMAN - Shri I. SURESH BABU

Complaint Ref. No.HYD-L-006-1920-0303

Award No. IO/HYD/A/LI/ 0292/2019-20

1. Name & address of the complainant Mrs Alluri Priyanka, DNo.3-117/A, Jonnalagadda post, Nandigama Mandal, Krishna Dist- 521185

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

0309649812 Bajaj Allianz Child Gain policy. 21Years/18Years

3. Name of the Policy holder Mr Alluri Prasad

4. Name of the insurer Bajaj life ins. Company limited

5. Date of repudiation 08/01/2019

6. Reason for Rejection As per conditions of policy.

7. Date of receipt of the Complaint 25/07/2019

8. Nature of complaint Repudiation of Death claim

9. Amount of Claim As per conditions of policy.

10. Date of Partial Settlement NIL

11. Amount of Relief sought As per conditions of policy.

12. Complaint registered under Rule No 13.1. ( b) of Insurance Ombudsman Rules

Dispute related to legal construction of policies.

13. Date of hearing/place 18/09-/2019/Hyderabad


a) For the complainant Self

b) For the insurer Mr.Arvind, Senior Executive


16. Date of Order/Award 11/02/2020

17) Brief Facts of the Case:

Mrs A. Priyanka complained that her husband took an insurance policy on 28-

12-2013 and he expired on 27-06-2018 due to accidental electrical shock while he was

on duty. As the claim was not admitted by the company, she decided to complain to

the Insurance Ombudsman for justice.

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

and so it was registered.

18) Cause of Complaint: Rejection of death claim

a) Complainants argument:

Mr. A.Prasad took an insurance policy in 12/2013 from Bajaj Allianz life

insurance company limited with his daughter as the life assured. He died on 27-06-

2018 due to electric shock. His wife, Ms.Alluri Priyanka gave death intimation to the

insurance company but the death claim was not admitted by the insurer stating that the

policy was in lapsed condition as on date of death of Mr.A.Prasad. The complainant

stated that, her husband set the policy premiums to auto debit from his Axis bank

account. Though her husband maintained sufficient balance in his bank account the

insurance company did’nt deduct the premiums and when she questioned the insurer

she was informed that the premium was not deducted due to technical problem. As

sufficient balance was maintained in the bank account the complainant requested the

insurer to admit the claim but the claim was not admitted.

b) Insurer’s argument:

An insurance policy bearing number 0309649812 was issued to Mr.A.Prasad on

28/12/2013. The company had received the death claim intimation wherein it was

mentioned that the life assured had expired on 27-06-2018. It was submitted that, on

receipt of death claim, the company looked into the matter internally and it was

observed that the policy was lapsed due to non-payment of premium as on date of

death of Mr.A.Prasad. Hence, the company has repudiated the claim as per the terms

and conditions of the policy.

19) Reason for Registration of Complaint: Rejection of death claim

20) The following documents were placed for perusal.

a) Complaint letter

b) Rejection letter by Insurer

c)Self contained note by the Insurer.

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

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

hearing held at Hyderabad on 18/09/2019.

On close consideration of the submissions made and documents produced by

both the parties it was observed that the policy in question was taken on 28/12/2013

and the mode of payment was monthly. As the policy holder had given option for

Electronic clearing service (ECS) payment, the premium was being recovered from his

bank account every month. The due date of payment of premium was 28th of the

particular month. It was mentioned in the policy document (page 9) that, for monthly

mode of payment of premiums, there would be a grace period of 15 days for payment

of premiums. The premium which was due on 28/01/2018 was recovered from the

bank account on 05/02/2018. The next due date of payment of premium was on

28/02/2018, but the policy holder did’nt maintain sufficient balance on 28/02/2018.

Anyhow, there was sufficient balance in the bank account from 01/03/2018 onwards

which was within the grace period but premium was not deducted from the bank

account. The complainant stated in the complaint letter that, as the premiums due on

28/03/2018 and 28/04/2018 were also not recovered, though the policy holder

maintained sufficient balance continuously from 01/03/2018 onwards, the policy holder

approached the insurer and enquired about the same. The policy holder was informed

that premium was not recovered due to technical reasons and he was advised to pay

the premiums personally. The policy holder paid all the three premiums due on

28/02/2018, 28/03/2018 and 28/04/2018 by credit card and the same was debited in his

bank account on 23/05/2018. The due date for the next premium was on 28/05/2018

but the policy holder did’nt maintain sufficient balance on 28/05/2018. Though, the

policy holder maintained sufficient balance from 01/06/2018 onwards which was within

the grace period, premium was not recovered from the bank account and the policy

holder expired on 27/06/2018. From 01/06/2018 onwards the policy holder maintained

sufficient balance in the bank account till the date of death

The contention of the insurer was that, for ECS mode of payments, premium

recovery would be effected from the bank account of the policy holder only once for a

due and if sufficient balance was not maintained as on date on which the premium

recovery was effected in the bank, then no attempt would be made to recover the

premium a second time for the same due and the policy holder has to pay the premium

personally. This condition was no where mentioned in the policy document. It was only

mentioned in the policy schedule (Page No.6) that for monthly mode of payment there

would be a grace period of 15 days for payment of premium. No special conditions

were mentioned in the policy regarding payment of premiums in the grace period for

ECS option payments. It is clear that, for regular payment options, the payment of

premium implies that the payment has to be paid by the policy holder and for ECS

option, payment of premium implies that the policy holder has to maintain sufficient

balance in the bank account and the premium would be deducted from the account. As

it was mentioned that, for monthly mode of payment, the premium could be paid within

the grace period, it implies that the policy holder has to maintain sufficient balance till

the grace period. As the policy holder had maintained sufficient balance from

01/06/2018 onwards which was well within the grace period, there was no default on

the part of the policy holder.

It was also observed that the premium was not recovered exactly on the due

date. For instance, the premium which was due on 28/01/2018 was not recovered on

28/01/2018 but it was recovered on 05/02/2018 which was more than one week after

the due date. If the due date happens to be a holiday the premium would have been

recovered on the next working day of the due date but the premium which was due on

28/01/2018 was deducted on 05/02/2018. As the premium was deducted after more

than one week after the due date the policy holder was of the opinion that the premium

would be deducted on any date within the grace period when sufficient balance was

available in the account and accordingly he maintained sufficient balance in the grace

period.

The contention of the insurer was that, the policyholder was aware that, if the

premium was not deducted from the bank account due to insufficient balance, then he

has to pay the premium personally, as he had previously paid the premiums due on

28/02/2018, 28/03/2018 and 28/04/2018 personally by credit card. This contention of

the insurer was not correct, as the complainant stated in the complaint letter that the

policy holder has paid the premiums personally on request of the insurer, as the insurer

informed the policy holder that the premiums were not recovered from his bank

account due to technical error.

In the repudiation letter dated 08/01/2019 the insurer had stated that the claim

was not admissible as the premium due on 28/05/2018 was not paid on due date or in

the 15 days of grace period i;e till 11/06/2018. As the policy holder has given ECS

option, payment of premium in the policy means maintaining sufficient balance in the

bank account. If sufficient balance is maintained in the bank account it amounts to

payment of premium only as far as the policy holder is concerned as it would be the

responsibility of the insurer to raise the debit

As the policy holder maintained sufficient balance in the bank account during the

grace period, it was clear that the insurer was at fault for not deducting the premium in

the grace period.

In view of the above Forum feels that, the decision of the insurer to reject the

claim was not correct.

AWARD

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

by both the parties during the course of personal hearing, the Insurer is directed to admit the claim and all the benefits, like premium waiver benefit, survival benefit and maturity benefit may be given to the beneficiary as per conditions of the policy. In result, the complaint is allowed.

Dated at Hyderabad on the 11th day of Febrauary 2020

( I SURESH BABU )

INSURANCE OMBUDSMAN FOR THE STATES OF A.P.






Award No. IO/HYD/A/LI/0293/2019-20

1. Name & address of the complainant Mr Balasani Vikram H.No. 12-10-366/5/1, Medibavi Seetaphalmandi Secunderabad -500061


400120329E Edelwiss Wealth Assure Plan 10 Years/5 Years

3. Name of the Policy holder Mr.B..Madhu

4. Name of the insurer Edelwiss Tokio life insurance co.ltd


6. Reason for Rejection Suppression of material facts.


8. Nature of complaint Repudiation of Death claim.

9. Amount of Claim Rs.3,65,570/-


11. Amount of Relief sought Rs.3,65,570/-

12. Complaint registered under

Rule No 13.1. ( b) of Insurance Ombudsman Rules

13. Date of hearing/place 05-02-2020/Hyderabad



b) For the insurer Mr.V.Kiran , Senior Executive.




Mr.Balasani Vikram complained that the insurance company wrongly rejected the payment of death claim on the death of his father. Hence, the complainant

decided to complain to the Insurance Ombudsman for justice.The complaint falls within

the scope of the Insurance Ombudsman Rules, 2017 and so it was registered. 18) Cause of Complaint: Repudiation of Death claim. a) Complainants argument:

Mr.B.Madhu took an insurance policy from Edelwiss life insurance company

limited on 22/02/2018.Unfortunately, he expired all of a sudden, on 10/04/2019.The

insurance company rejected the claim stating that he has suppressed material fact

regarding his medical history. The complainant stated that the medical history of the

deceased life assured was disclosed to the manager who filled up the proposal form

but the manager did’nt mention the same in the proposal.


An insurance policy was issued on 22/2/2018 on the basis of the proposal for

insurance on the life of Mr.B.Madhu. His son Mr.B.Vikram, who was the nominee in the

policy gave a death intimation stating that, the life assured expired on 10th April 2019

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

assured was suffering with health issues before taking the policy but did’nt disclose

the same in the proposal form Had the true and correct facts pertaining to Life

Assured’s past medical history been disclosed at the proposal stage, company would

not have issued the aforesaid policy at all. Hence, the insurance company repudiated

the claim and the same was intimated to him on 12/06/2019.



a)Policy schedule

b) Complaint letter

c) Rejection letter by Insurer

d)Self contained note by the Insurer.

21) Result of hearing with both the parties (observations & conclusion) :


hearing held in Hyderabad on 05/02/2020

During the course of hearing the insurer reiterated what had been mentioned in

the self contained note and the complainant repeated the contents of the complaint

letter.On close consideration of documents produced and submissions made by both

the parties it was observed that the life assured Mr.B.Madhu had taken the policy on

22/02/2018 and he expired on 10/04/2019. As it was an early claim the insurer

conducted an investigation and some indisputable evidences were procured by the

company which substantiate the fact that the life assured suffered from diabetes,

hypertension and had undergone PTCA (Percutaneous Transluminal Coronary

Angioplasty) and stent procedure prior to the proposal date and the said fact was not

disclosed by the deceased life assured at the time of taking the policy. The insurer had

also submitted medical reports dated 14/12/2017, which was prior to the proposal

date,from NIMS hospital, Hyderabad, where the deceased life assured had taken

treatment.

The complainant did’nt dispute the medical reports, but the contention of the

complainant was that, the life assured did’nt fill up the proposal form but the form was

filled by the manager of the company. The medical history of the life assured was also

disclosed to the manager, but he did’nt mention the same in the proposal from. It was

surprising to note that the complainant who was the son of the deceased life assured

and also the nominee in the policy was himself the agent who procured the policy.

Hence, it was clear that the complainant was aware that the proposal was being

submitted without mentioning the medical history of the life assured. Being an agent, he

was aware of the importance of disclosing the medical record of the life assured in the

proposal form, but he kept quite when the manager was stated to have submitted the

proposal without mentioning the medical history.

The above facts clearly establish that there was concealment of material fact

regarding the past medical history of the life assured before taking the policy. Hence,

there has been a breach of one of the basic principles of Life insurance contract

‘Uberema Fides” which is Utmost Good faith. The doctrine of good faith requires the

proposer to make a complete and truthful disclosure of the material facts pertaining to

his health and other details in the proposal form but there was a suppression of

material fact regarding the medical history of the life assured.

As the complainant himself was the agent and, as he had also not disputed the

medical history of the life assured and he had also admitted that the medical history

was not disclosed in the proposal, Forum feels that the repudiation of the death claim

by the insurer was legal and correct.

AWARD

Taking into account the facts & circumstances of the case, the documents produced

and submissions made by both the parties during the course of hearing the repudiation

of the death claim by the insurer is justified.

In result, the complaint is Dismissed.


(I.SURESH BABU)

INSURANCE OMBUDSMAN FOR THE STATES OF A.P., TELANGANA AND YANAM




Complaint Ref. No. HYD-L-019-1920-0276,0337

Award No. IO/HYD/A/LI/ 0294& 0295/2019-20

1. Name & address of the complainant Sri Somireddy Satyanarayana Reddy, HNo.4-28, Atmakur, SuryapetaDist, Telagana state- 508213


18613062 & 19658384 HDFC Life SampoornSamridhi plan 15Years/07Years

3. Name of the Policy holder MsSomireddy Sri Maha

4. Name of the insurer HDFC Std. life insurance Co Ltd


6. Reason for Rejection Suppression of material fact.



9. Amount of Claim Rs.11,50,000/-Rs.11,56,520/-.


11. Amount of Relief sought Rs.11,50,000/-Rs.11,56,520/-.

12. Complaint registered under Rule No 13.1. ( b) of Insurance

Dispute related to legal construction of policies.

Ombudsman Rules

13. Date of hearing/place 18/09/2019/Hyderabad



b) For the insurer Mr.Nagarjuna, Associate Manager.




Sri Somireddy Satyanarayana Reddy complained that the insurer had wrongly repudiated the claims on two policies on the death of his daughter who was the life assured. Hence, the complainant decided to complain the insurance ombudsman for justice.

The complaint falls within the scope of the Insurance Ombudsman Rules, 2017 and so it was registered. 18) Cause of Complaint: Repudiation of Death claim. a) Complainants argument:

Sri Somi Reddy Satyanarayana Reddy took 5 insurance policies on the life of

his daughter Ms. Somireddy Sri Maha from HDFC Life insurance company limited.

Unfortunately, his daughter died of fever and the insurance company has settled the

claims on 3 policies out of 5 policies. The insurance company has repudiated the death

claim on two policies with the reasons “non disclosure of pre-existing diseases”. The

complainant informed the insurer that the life assured did’t suffer from any pre-existing

disease before taking the policy, and hence he requested the insurance company to

reconsider it’s decision and settle the death claims. The insurer did’nt settle the death

claim and hence the complainant approached the Forum for justice.


The Complainant Mr.S.Satyanarayana Reddy has taken five insurance policies

with his daughter Ms.S.Srimaha as the life assured. A death intimation was received

from him stating that she expired on 21/02/2019 due to high fever. The death claims on

three policies were settled immediately as they were non-early claims. As the claims

on the other two policies were early claims, an investigation was conducted and it was

found in the investigation that the deceased life assured was suffering from

‘’Macrocephaly and neurological deformity” since her birth and the same was not

disclosed in the proposal Forms. As there was suppression of material facts, the claim

was repudiated.

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


a)Policy schedule

b) Complaint letter





hearing held at Hyderabad on 18/09/2019.

On close consideration of submissions made by both the parties it was observed

that the insurer had repudiated the claim stating that the life assured suffered from pre-

existing disease but the same was not disclosed in the proposal forms. In the self

contained note the insurer stated that the deceased life assured was being regularly

treated at PHC, Atmakur and the treating doctor Mr.Raj Kumar confirmed vide

certificate dated 23/04/2019 that she was suffering from macroceplaly and neurological

deformity.This contention of the insurer does’nt hold any ground as the doctor has

retracted and gave another certificate dated 24/09/2019 stating that she was not

treated or examined by him.

It was observed that the insurer had repudiated the claim on the basis of the

investigation report submitted by an investigator. It was mentioned in the investigation

report that the neighbors and relatives of the deceased life assured had informed that

she was suffering from birth defect and unable to walk since birth. It was also

mentioned that the life assured was given regular treatment at Primary Health center,

Atmakur, but there was no medical record to establish the same. The only record

submitted was the certificate issued on a white paper with stamp and signature of

Dr.Raj Kumar, Medical officer of Primary Health center, Atmakur. It was mentioned in

the certificate that the life assured was suffering from birth with ‘’Macrocephaly and

neurological deformity’’ and unable to move from pelvis to lower limbs. It was also

mentioned in the certificate that she was bed ridden from birth. The contention of the

Doctor that she was bedridden from birth does’nt seem to be correct as the

complainant had submitted a 10th class school certificate of the life assured from

Z.P.High school, Atmakur, which confirms that she was a school going child. A letter

was written by this office to the Doctor to confirm the genuineness of the certificate

dated 23/04/2019 given by him. A reply dated 24/09/2019 was received from the

Doctor stating that the life assured Ms.Sri Maha was not treated and examined by him.

As it was not correct to issue a certificate that a person was suffering from an ailment

without treating or examining a person, Forum felt that the Doctor might have issued

the certificate on the request of the investigator. The same was informed to the insurer

and a copy of the letter was sent to the insurer. A reply dated 08/01/2020 was received

from the insurer stating that, though the Doctor has informed that he had not examined

or treated her, the Doctor has also not denied that he had issued the certificate stating

that the life assured was suffering from birth defect. The insurer also stated that the life

assured was taken to the Doctor on 21/02/2019 in a critical condition and he referred

her to higher center for further treatment. The insurer further stated that ‘Macrocephaly’

was not an internal birth defect but an external birth defect and to confirm that the life

assured was suffering from ‘Macrocephaly’ it was not required to examine her or treat

her. This contention of the insurer was not correct as the Doctor has not stated that the

life assured was bought to him in critical condition on 21/02/2019 but the Doctor has

only stated that the she was taken to a private hospital at Suryapet on 21/02/2019 and

she was examined and suggested for further treatment at higher center but

unfortunately she expired on the way.

The Doctor, Mr.Rajkumar has given another letter dated 11/12/2019 stating that,

on the instructions of District Medical & Health Officer, Suryapet he deputed one Multi

purpose health assistant to assess the reasons of the death of Ms.Srimaha and on the

basis of her findings he had submitted an assessment report. It was clear that the life

assured was never taken to him for any treatment but he had given the report only after

her death on the basis of the findings of the health assistant . The doctor has further

stated that he has crosschecked the information with the complainant’s neighbors and

relatives who visited him for treatment and they too confirmed the same. This

contention of the doctor was also not correct as the certificate given by the doctor

without any medical tests or treatment but only by oral submissions of others is not

valid.

The insurer had also submitted a medical record dated 20/02/2019 from Gayatri

Nursing Home which was one day before her death. It was mentioned in the

investigation report that she was shifted to the hospital with high grade fever where

doctors referred her to higher center and while shifting to another hospital she expired

on the way. The insurer did’nt submit any discharge summary of Gayatri Hospital. It

was also not mentioned anywhere in the medical record of Gayatri Hospital that she

suffered with ‘Macrocephaly or neurological disorder’.

Rejection of death claim as per section 45 of the insurance Act,1938 warrants

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

insurer failed to provide any convincing evidence by way of medical tests or treatment

history to substantiate the existence of any disease before taking the policy.

Repudiating a claim on the basis of a letter given by a doctor who never treated or

examined the life assured was not correct.

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

was not correct and the death claims on both the policies may be settled.

AWARD


and submissions made by both the parties during the course of hearing the insurer is

directed to settle the death claims on both the policies.

In result, the complaint is Allowed.

Dated at Hyderabad on the 14th day of Febrauary 2020.

( I SURESH BABU )

INSURANCE OMBUDSMAN FOR THE STATES OF A.P. TELANGANA AND CITY OF YANAM






1. Name & address of the complainant Mrs P.Ilamma Flat No.102, HNo.7-10-2, Nice Residency, Raghavendra Nagar colony, Near Sai Baba Temple. Warangal- 500076


03518578 Reliance life Smart Term Insurance Plan. 29 Years/29 Years

3. Name of the Policy holder P.Komuraiah

4. Name of the insurer Relaince life insurance Company Limited


6. Reason for Rejection Suppression of material facts


8. Nature of complaint Repudiation of death claim.

9. Amount of Claim Rs.121000


11. Amount of Relief sought Rs.121000



13. Date of hearing/place 12/02//2020/Hyderabad


a) For the complainant

b) For the insurer

15. Complaint how disposed

16. Date of Order/Award


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

settle the death claim on the policy of her husband. Hence, she decided to complain to

the Insurance Ombudsman.



18) Cause of Complaint: Repudiation of death claim.


Mr P.Komuraiah took an insurance policy on 12/01/2011 from Relaince life

insurance and he expired on 12/12/2018. His wife, Ms.P.Ilamma who was the nominee

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

The insurer repudiated the claim stating that the deceased life assured committed

suicide within one year of reinstatement of the policy. Hence, the complainant decided

to complain to the insurance Ombudsman for justice.

19) Reason for Registration of Complaint:-

An insurance policy bearing number 18395388 was issued to Mr.P.Komuraiah

after receiving the duly completed and signed proposal form on 12/01/2011. A death

intimation was received from his wife who was the nominee in the policy stating that the

life assured expired on 12/12/2018. As it was an early claim an investigation was

conducted and it was revealed that the life assured committed suicide within one year

of reinstatement the policy. Hence the claim was repudiated as per conditions of the

policy and the same was informed to the nominee vide repudiation letter dated

28/02/2019.


a)Policy schedule

b) Complaint letter





hearing held at Hyderabad on 12/02/2020

On close consideration of submissions made and documents produced it was

observed that the deceased life assured Mr.P.Komuraiah had taken the policy on

12/01/2011. He paid premiums regularly till 2017. The premium due on 12/01/2018 was

not paid in time and eventually the policy went into a lapsed condition. The policy

holder paid the premium on 25/02/2018 and the policy was reinstated. The life assured

expired on 12/12/2018, which was within one year of reinstatement of the policy. The

insurer repudiated the death claim stating that the claim was not payable as the life

assured had died by committing suicide within one year of reinstatement of the policy.

Though the complainant had not mentioned the cause of death in the complaint letter

given to the Forum, the cause of death was mentioned as suicide in the letter given by

the complainant to the insurance company. During the course of hearing the

complainant had also agreed that the cause of death was suicide.

The contention of the complainant that, the notice for payment of premium was

not sent by the insurer was not acceptable as it was clearly mentioned in the premium

collection receipt of 2017 that the next renewal date was 12/01/2018. It was also

mentioned in page No.3 of the policy document that there would be a grace period of

30 days for payment of premium if the mode of payment of premium was annual. As

the due date of the payment of premium was 12/01/2018, the grace period for payment

of premium expired on 12/02/2018. Hence, it was clear that the life assured was aware

that the grace period would expire on 12/02/2018.

It was also mentioned in the policy document (Point No.9) that , the company

would not pay any claim on death, if the life assured whether sane or insane, commits

suicide within 12 months from the date of issuance of the policy or the date of any

reinstatement of the policy.

In view of the above, Forum does not see any need to interfere with the

decision taken by the insurer to repudiate the claim as the insurance company had

repudiated the claim purely as per terms and conditions of the policy and action taken

by the insurer was correct.

AWARD

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

both the parties during the course of hearing the insurer is justified in repudiating the

death claim.

In result the complaint is Dismissed


( I SURESH BABU )

INSURANCE OMBUDSMAN FOR THE STATES OF A.P. TELANGANA AND CITY OF YANAM




Complaint Ref. No. HYD-L-019-1920-0502


1. Name & address of the complainant S Naveen Kumar 1-82, Andhra Basti, Guttala Begumpet, Kondapur, Serilingampally, Hyderabad- 500084


1F000112 HDFC Group credit protect plus plan. One Year/ Single Premium.

3. Name of the Policy holder Mr.S.Naveen Kumar

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

5. Date of repudiation 16/08/2019.

6. Reason for Rejection Suppression of Material Facts.


8. Nature of complaint Repudiation of Death Claim

9. Amount of Claim Rs.5,00,000/-.


11. Amount of Relief sought Rs.5,00,000/-.



13. Date of hearing/place 11/12/2019- Hyderabad



b) For the insurer Mr.P.Krishna, Deputy Manager.

15. Complaint how disposed Allowed.

16. Date of Order/Award 19/02/2020.


Sri S.Naveen Kumar complained that the payment of Death claim on the life of

his father was wrongly rejected by the company with the reasons “suppression of

material facts”. Hence, he decided to complain to the Insurance Ombudsman for

justice.



18) Cause of Complaint: Repudiation of death claim


Mr. S.Prem Chand took an insurance policy on 09/02/2019 with HDFC life

insurance company limited through PAYTM APP. The life assured expired on

28/02/2019 and his son, Mr.S.Naveen kumar who was nominee in the policy,gave

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

rejected the claim stating that the insured was suffering from recurrent jaundice, prior

to the date of proposal but did’nt declare the same in the proposal form. The

complainant, Mr.S.Naveen Kumar stated that the person who had registered the policy

did not enquire about the health of the life assured before booking the policy and

registered the policy through online. Since, the policy was under Non- Medical, the

complainant felt that it was not correct to repudiate the claim. Hence, he decided to

approach the insurance Ombudsman for Justice.


A Group term insurance policy bearing number IF000112 was issued to

Mr.S.Prem Chand on 09/02/2019. A death intimation was received from his son

Mr.S.Naveen Kumar stating that the life assured expired on 28/02/2019. An

investigation was conducted and it was found that the life assured was suffering from

Recurrent Jaundice since one year but did’nt disclose the same while taking the policy.

The proposal was accepted at standard rates based on the information provided in the

member enrolment form and the policy was issued. The declaration form filled in by the

deceased stated that he did not suffer from any ailment prior to the date of proposal. As

there was suppression of material fact regarding health condition of the life assured,

the claim was repudiated.

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


a) Certificate of Insurance.

b) Complaint letter





hearing held in Hyderabad on 11/12/2019.

On close consideration of submissions made by both the parties during the

course of personal hearing, it was observed that, Mr. S.Prem Chand had taken a HDFC

Life Group Term Insurance plan on 09/02/2019 for a sum assured of Rs. 5,00,000/-.

As the life assured expired on 28/02/2019, which was within 20 days of taking the

policy, the insurer investigated into the claim and found that the life assured was

suffering from Recurrent Jaundice since one year. It was also found that the deceased

life assured was a chronic alcoholic with a history of Alcoholic liver disease but the life

assured suppressed this fact and gave declaration of good health while taking the

policy. Basing on the declaration of good health, he was issued the policy with standard

rates.

The complainant did’nt dispute the contention of the insurer regarding the health

history of the deceased life assured but the argument of the complainant was that, the

declaration of good health was not asked while issuing the policy.

During the course of hearing, the representative of the insurer stated that, the

policy was taken through PAYTM APP and once the proposer entered into the option,

he would be prompted to a web page containing the good health declaration and only if

the customer clicked on the good health declaration, declaring that he did not have any

previous ailment, the APP allowed the customer to proceed further with submission of

the proposal. The representative of the insurer further stated that an individual policy

was not issued to the life assured but a group policy was issued to M/s. ONE 97

Communications limited which owned the PAYTM APP. All the PAYTM customers

accessing the APP had the option to avail the insurance cover by declaring about their

good health.

The insurer issues many policies by obtaining proposal forms through online and

in all such cases, except the signature of the proposer, the proposal form contains all

the columns duly filled which are generally available in proposal forms which are

manually submitted. In group term policies membership form would be taken instead of

proposal form. In the repudiation letter dated 16/08/2019, sent by the insurer, it was

mentioned that, in the membership enrolment form the life assured had given a

declaration of good health stating that he does’nt have any adverse health history. The

insurer was directed to submit the copy of the membership form obtained from the life

assured containing the good health declaration but the insurer submitted only the

wordings of the declaration of good health form but not the copy of the actual

membership form obtained from the life assured as mentioned in the repudiation letter

sent by the insurer. The proposal from (membership form) has lot of significance and

had evidentiary value. If the life assured.discloses wrong information regarding his

health in the said form, this amounts to suppression of material facts and the contract

is liable to be cancelled. In this context, the insurer was directed to submit the proposal

form (membership form) which contained the health declaration of the life assured.The

insurer could’nt do so.In the absence of any health declaration, the life assured could’nt

be accused of suppressing the material facts. The non submission or absence of health

declaration lends credence to the argument of the complainant that no such health

declaration was called for. It is opined that charges against the life assured about the

wrong declaration of good health does’nt hold ground in the absence of such

declaration. Hence the claim of the insurer remains unproved and unsubstantiated.

As the insurer was not able to submit any corroborative evidence to establish

that a declaration of good health was submitted by the life assured, Forum feels that

the repudiation of death claim was not justified.

AWARD


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

In result the complaint is Allowed.

.

Dated at Hyderabad on the 19th day of February 2020.

( I SURESH BABU )

INSURANCE OMBUDSMAN








1. Name & address of the complainant Mr ,J.Srinu K.P.Agraharam Village Door No. 2-7B ( Post), Butchiyya peta,, Visakhapatnam (Dst) Andhra Pradesh-531026


03631589 Kotak Classic Endowment Plan 15 Years/10 Years

3. Name of the Policy holder Ms.C.Chilukamma

4. Name of the insurer Kotak life insurance Co.Limited

5. Date of rejection 04/09/2019

6. Reason for Rejection Age understated in proposal.





11. Amount of Relief sought Rs.2,20,360/-



13. Date of hearing/place 12-02-2020/Hyderabad



b) For the insurer Ms.Rupkatha Basu, Senior Executive.




Mr.J.Srinu complained that the insurance company has wrongly repudiated the

death claim on the policy of his mother.Hence, he decided to complain to the Insurance

Ombudsman for justice.The complaint falls within the scope of the Insurance

Ombudsman Rules, 2017 and so it was registered.

18) Cause of complaint : Repudiation of death claim.

a) Complainant’s Argument:

Ms.J.Chilukamma took an insurance policy from kotak life insurance company

limited on 10/03/2017. Unfortunately, the life assured passed away on 03/10/2017.

The complainant submitted the claim forms to the insurance company but the

Insurance company rejected the claim stating that the policy was already cancelled as

the life assured had taken the policy by understating her age in the proposal from.The

complainant requested the insurer to reconsider their decision and settle the claim

stating that the age mentioned in the proposal was true. As the insurer did’nt agree to

settle the claim the complainant decided to complain to the Insurance Ombudsman.


An insurance policy bearing number 03631589 was issued to Ms.J.Chilukamma

on 10/03/ 2017 after receiving the duly completed and signed proposal form. A death

intimation was received from the nominee of the life assured stating that the life

assured expired on 03/10/2017. As it was found that,the life assured has taken the

policy by understating her age the policy was already cancelled and the premium was

refunded to the life assured on 30/10/2017, hence the claim was rejected and the same

was informed to the nominee.



a)Policy schedule

b) Complaint letter


d) Self contained note by the Insurer.

21) Result of hearing with both the parties (observations & conclusion) :


hearing held in Hyderabad on 12/02/2020.

During the course of hearing the insurer reiterated what had been mentioned in

the self contained note and the complainant repeated the contents of the complaint

letter. On close consideration of documents produced and submissions made by both

the parties it was observed that, the policy was issued by the insurer to the life assured

on 10/03/2017 by accepting her Adhaar card as the Age proof in which the date of

birth was mentioned as 01/01/1961. Hence, the age of the life assured as on date of

policy as per Adhaar card was 56 years. After issuing the policy, the insurer came to

know that, the age of the life assured as per the voter list was 71 years as on date of

policy. As the maximum age upto which the policy could be given was only 60 years,

the insurer issued a show cause notice dated 29/09/2017 to the life assured seeking

clarification regarding the discrepancy in the age of the life assured. The insurer also

mentioned in the letter that, in absence of a response from the life assured within a

period of seven days post receipt of the letter, the company shall be bound to consider

the same as an implied admittance of the discrepancy in age and the policy shall be

cancelled without intimation. As the life assured did’nt respond to the letter, the insurer

cancelled the policy and refunded the premium amount of Rs.25,000/- paid by the life

assured. Later, the company received a claim intimation on 15/03/2019 from the

nominee informing that the life assured had expired on 03/10/2017. The insurer

repudiated the claim as the first premium paid by the life assured was already

refunded on 30/10/2017 after cancelling the policy. When the complainant was asked

as to why claim intimation was given after 14 months of death of the life assured, he

informed that he was in Dubai in that period and he did’nt even come to attend the

death ceremony of his mother due to financial problems.

During the course of hearing the complainant stated that the show cause notice

dated 29/09/2017 was not received and the representative of the insurer was also not

able to show any acknowledgement of the life assured having received the notice. As

the policy was cancelled and premium paid by the life assured was refunded after the

death of the life assured, the possibility that the insurer cancelled the policy and

refunded the premium after coming to know that the life assured had expired could’nt

be ruled out. The fact that the insurer could’nt show any evidence of the life assured

being served the letter regarding cancellation of the policy gives strength to the

possibility.

During the course of hearing the complainant submitted copy of ration card and

the age of the life assured on the basis of the ration card was 55 years as on date of

taking the policy which is only one year less than her age as per her Adhaar card

which can be ignored as ration card is a non standard age proof. Out of the three age

proofs submitted (Adhaar card, Ration card and voter list) the age of the life assured as

on date of the policy was almost same as per two age proofs ( Age 56 years as per

Adhaar card and Age 55 years as per Ration card).Hence, the benefit of doubt could be

given to the life assured and the age as per her Adhaar card submitted along with the

proposal form can be treated as genuine. It was also observed that the nominee who

was the son of the life assured had submitted his PAN Card, and his age as on date of

policy as per his PAN Card was 34 years. As the age of the life assured as on date of

policy was 56 years, there was a difference of 22 years between the ages of the life

assured and her son which seems to be genuine.

It was also observed that the age of the life assured as per voter list and voter

card was also not same. As per voter card age of the life assured as on date of policy

was 77 years and age as per voter list was 71 years as on date of policy. Hence, the

voter list and voter card could’nt be taken into consideration for arriving at the age of

the life assured as the age as per voter list and voter card should be same, but it was

different. Had the insurer cancelled the policy after arriving at the age on the basis of

standard age proof, the cancellation of the policy would have been justified. After

issuing the policy by taking the age of the life assured as per her Adhaar card, now the

insurer cannot go back and cancel the policy by taking the voter list as a basis for her

age as the voter list is also a non standard age proof and the age mentioned in the

voter list also does’nt seem to be genuine.

As it is observed that there was no fraudulent intention on part of the life

assured, the representative of the insurer was asked during the course of hearing as to

what would have been the motive of the life assured in taking the policy by

understating her age. The representative of the insurer stated that it was found in their

investigation that the life assured was suffering from TB before taking the policy and

hence she decided to take the policy by understating her age as she would not be

eligible for the policy if her actual age was known. This contention of the insurer

could’nt be accepted as the insurer could’nt submit any evidence to establish that the

life assured was suffering from T.B before taking the policy.

In view of the above Forum feels that the insurer had erred in repudiating the

claim by stating that the life assured had taken the policy by understating her age

without any corroborative evidence to establish the same. Hence, the ends of justice

would be met if the death claim is settled.

AWARD


and submissions made by both the parties during the course of hearing the insurer is

directed to settle the death claim. .

In result, the complaint is Allowed.


(I.SURESH BABU)

INSURANCE OMBUDSMAN FOR THE STATES OF A.P., TELANGANA AND YANAM




Complaint Ref. No. HYD-L-019-1920-0400


1. Name & address of the complainant Ms.Annapragada Srividya, C/o. A.V.Subba Rao, 501, Bhavyas Majestic Enclave, Madhavanagar Colony, Miyapur, Hyderabad- 500049


15600895. HDFC SL Youngstar Super Premium 15 Years/15Years

3. Name of the Policy holder Mr.Rohit Agarwal.

4. Name of the insurer HDFC Std. life insurance Co Ltd

5. Date of rejection by insurer 05/02/2019

6. Reason for Rejection Requirements not submitted.


8. Nature of complaint Death claim not settled

9. Amount of Claim Rs.15,00,000/-.


11. Amount of Relief sought Rs15,00,000/-.

12. Complaint registered under Rule No 13.1. ( b) of Insurance

Ombudsman Rules

13. Date of hearing/place 30/10/2019–Hyderabad


a) For the complainant Mr. A.V.Subba Rao, Father of the complainant.

b) For the insurer Mr.M.Krishna , deputy Manager.


16. Date of Order/Award 28/02/2020.


Ms.A.Sri Vidya complained that the death claim on the policy of her husband

Mr. Rohit Agarwal was not settled by the HDFC Standard life insurance company. The

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

was registered.

18) Cause of Complaint: Death claim not settled


Mr.Rohit Agarwal took an insurance policy from HDFC Life Insurance Company

on 27/11/2012. His minor son, Mr. Rohan Agarwal was the beneficiary(nominee) and

his wife Ms.A.Vidya was the Appointee in the policy. The life assured Mr. Rohit Agarwal

expired on 24/09/2018 and Ms.A.Sri Vidya gave death intimation and submitted the

required documents to the insurer and requested the insurer to settle the death claim.

As the insurer did’nt settle the death claim she approached the Insurance Ombudsman

for justice.


An Insurance policy bearing number 15600895 was issued to Mr.Rohit Agarwal

on 27/11/2012. A death intimation was received from Ms. Srividya who was the

appointee in the policy, stating that the life assured expired on 24/09/2018. As per the

claims procedure and policy terms the insurer had sought production of PAN Card,

Adhaar Card, Previous insurance details, Past and present medical records of the life

assured, original death certificate, cause of death, FIR, Post Mortem report. The same

was informed to the claimant vide mail dated 20/03/2019, but she did’nt respond. As

the requirements were not submitted by the claimant, the death claim was not settled.

19) Reason for Registration of Complaint:- Death claim not settled


a)Policy schedule

b) Complaint letter



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

Pursuant to the notices issued by this office representatives of both the parties

attended the hearing held in Hyderabad on 30/10/2019.

On close consideration of submissions made by both the parties during the

course of personal hearing, it was observed that the policy in question was taken on

27/11/2012 and his minor son Mr. Rohan Agarwal was the beneficiary(Nominee) and

Ms. A. Sri Vidya, wife of the life assured was the Appointee in the policy. The life

assured Mr.Rohit Agarwal got separated legally with his wife Ms.A. Sri Vidya and the

divorce was approved by court order dated 19/01/2018 and their son Mr. Rohan

Agarwal was staying with Ms.A.Sri Vidya as per court orders. The life assured was

staying separately as a paying guest at Bangalore. He fell sick in June 2018 and was

diagonised with Pneumonia. On 24/09/2018 Mr.Amit, the landlord of the paying guest

accommodation complained to the local police station suspecting something wrong as

Mr.Rohit Agarwal did’nt respond to his calls and the calls of his sister who called from

Delhi. The police broke open the door of Mr.Rohit’s room and found him dead. The

police booked an FIR and a post mortem was also conducted.

Ms.A.Sri Vidya gave death intimation and submitted the required documents to

the insurer and requested for settlement of death claim. During the course of hearing

the representative of the insurer informed that, the claimant had not submitted the

required documents and the representative of the complainant informed that the post

mortem report was not available. The representative of the complainant was advised by

the Forum to submit the post mortem report and a rehearing of the complaint was

conducted 31/12/2019 and the representative of the complainant submitted the post

mortem report.

In the self contained note (point no.3) the insurer stated that, the claimant was

advised to submit PAN Card and Adhaar card, Previous insurance details of the life

assured, Past and present medical records of the life assured, cause of death, Original

death certificate of the life assured , FIR copy and Post Mortem report. It was observed

that the claimant had already submitted the copies of Adhaar card and PAN card,

Original death certificate, FIR copy and post mortem report. Regarding the previous

insurance details of the life assured, it was already mentioned in the proposal form that

the life assured did’nt have any other insurance policies. Hence the question of

submission of previous insurance details does’nt arise. As the life assured had already

stated in the proposal form that, he did’nt have any adverse past medical history,

insisting on submission of past medical records is not correct. Regarding the present

medical records the claimant had already submitted the Post mortem report by Dr.

K.G.Ravi Raj and the claimant had further submitted that no other medical records of

the life assured are available. As the claimant had legally separated from the life

assured and staying separately, it would not be possible for the claimant to obtain the

medical reports of the deceased life assured. Even if it was assumed that the life

assured had an adverse medical history, being a non early claim, the medical reports of

the life assured before taking the policy do not have any significance. It was also

understood from the Post Mortem report that the proximate cause of death was lung

infection. Hence, it was clear that there was no foul play and the death of the life

assured was natural.

In view of the above, Forum feels that the insurer may admit the death claim

and settle the benefits in the policy.

AWARD

Taking into account the facts and circumstances of the case, the documents produced

and submissions made by both the parties during the course of hearing, the insurer is

directed to admit the claim and settle the benefits in the policy.

In Result the complaint is Allowed.

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

Insurance Ombudsman Rules, 2017:

g) According to Rule 17(6) the insurer shall comply with the award within 30 days of the receipt of the award and intimate compliance to the same to the Ombudsman.

h) According to Rule 17(7) the complainant shall be entitled to such interest at a rate per annum as specified in the regulations, framed under the Insurance Regulatory & Development Authority of India Act from the date the claim ought to have been settled under the Regulations till the date of payment of the amount awarded by the Ombudsman.

i) According to Rule 17 (8) the award of Insurance Ombudsman shall be binding on the Insurers.

Dated at Hyderabad on the 28th day of February 2020.

( I SURESH BABU )

INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF ODISHA

(UNDER RULE NO: 16(1)/17of

THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – Shri Suresh Chandra Panda

CASE OF (Smt. Sulochana Ghadei Vs. HDFC Standard Life Ins. Co.ltd)

COMPLAINT REF: NO: BHU-L-019-1920-0164

AWARD NO:BHU-A/LI/210/2019-2020

1. Name & Address of the Complainant Smt. Sulochana Ghadei, C/O- Girish Ghadei

At/Po- Mahulpal, Via/Ps Kamakshyanagar

Dhenkanal- 759018

2. Policy No:

Type of Policy


13723896

Life

11.06.2010



Girish Ghadei

- do-

4. Name of the insurer HDFC Standard Life Insurance

5. Date of Repudiation NA

6. Reason for repudiation NA

7. Date of admission of the Complaint 15.07.2019

8. Nature of complaint Non-payment of death claim

9. Amount of Claim 100000/-

10. Date of Partial Settlement NA

11. Amount of relief sought 100000/-

12. Complaint registered under Rule no: of

Insurance Ombudsman Rules

13(1)(b)

13. Date of hearing/place 13.02.2020/ Bhubaneswar


For the Complainant Sulochana Ghadei

For the insurer Surendra Panigrahi

15 Complaint how disposed Under Insurance Ombudsman Rule 17.

16 Date of Award/Order 13.02.2020

17) Brief Facts of the Case:- The above said policy was purchased by the husband of the complainant on

11.06.2010 from the present insurer. But unfortunately he died on 10.09.2010 due to high fever. After his

death the complainant being the nominee in the said policy applied for payment of death claim. But till date

the insurer has not made any payment. Hence, being aggrieved she approached this forum for redressal.

The insurer on the other hand submitted SCN stating that Life Assured had purchased the above

Endowment Assurance plan for an annualized premium of Rs. 10000/- with premium paying and policy term

of 15 years. Death intimation was received by the insurer through online on 24.08.2016. After receipt of the

same, the complainant was requested to visit the nearest HDFC Life branch and submit the original

documents for consideration of death claim. However, till date no document is received by the insurer for

which it is delayed.


a) Complainant’s argument:- The complainant stated that the above said policy was purchased by her

husband on 11.06.2010 from the present insurer. But unfortunately he died on 10.09.2010 due to high fever.

After his death the complainant being the nominee in the said policy she applied for payment of death claim.

All the papers were collected from her by the concerned agent. But till date the insurer has not made any

payment.

b) Insurers’ argument:- The insurer on the other hand pleaded that Life Assured had purchased the above

Endowment Assurance plan for an annualized premium of Rs. 10000/- with premium paying and policy term

of 15 years. Death intimation was received by the insurer through online on 24.08.2016. After receipt of the

same, the complainant was requested to visit the nearest HDFC Life branch and submit the original

documents for consideration of death claim. However, till date no document is received by the insurer for

which it is delayed.

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

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


a) Photo copies of policy documents.

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

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

submissions of both the parties it was observed that although death occurred just after 3 months after the

commencement of the policy, claim seems to be genuine. All the papers were also collected from the

complainant by the concerned agent. Hence, she expressed her inability to submit another set of claim

papers in the office. Moreover, the complainant is an illiterate lady and hails from a remote village of

Dhenkanal District. So expecting a fresh new set of claim papers from her for settlement of claim is not

possible. Xerox copies of death certificate and other treatment papers which were submitted by the

complainant in the office were supplied to the insurer instantly at the time of hearing. Hence, this forum is of

the opinion that the insurer should admit the claim on the basis of these papers and depute some officer of

the local branch to help the complainant to comply the additional requirements if any for early settlement of

the claim.

AWARD

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

parties during the course of hearing, the insurer is directed to admit the claim on the basis of

papers collected at the time of hearing and help the complainant to comply the additional

requirements if any for early settlement of the claim.

Hence, the complaint is treated as allowed accordingly.

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


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

the Award within 30 days of the receipt of the award and shall intimate the compliance to the

Ombudsman.

b. As per rule 17(7) the complainant shall be entitled to such interest at a rate per annum as specified in the

regulations framed under the Insurance Regulatory and Development Authority of India Act 1999, from

the date the claim ought to have been settled under the regulations, till the date of payment of the amount

awarded by the Ombudsman

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

the Insurers.

Dated at Bhubaneswar on 13th Feb. 2020

(SURESH CHANDRA PANDA)

INSURANCE OMBUDSMAN

FOR THE STATE OF ODISHA

PROCEEDINGS BEFORE





CASE OF (Smt. Sabita Das Vs. LIC of India Cuttack DO)


AWARD NO: BHU-A/LI/224/2019-2020

1. Name & Address of the Complainant Mrs. Sabita Das, W/O- Late Manoj Kumar Das,

Vill/Po- Inchudi, Via- Rasalpur, Dist- Balasore

756021

2. Policy No:

Type of Policy


598011372 & 588063628

Life

26.04.2010 & 28.03.2007



Late Manoj Kumar Das

- do-

4. Name of the insurer LIC of India Cuttack DO


6. Reason for repudiation



9. Amount of Claim 4 lakh


11. Amount of relief sought 4 lakh



13(1)(b)



For the Complainant H K Das

For the insurer Sunita Panda



17) Brief Facts of the Case:- The above said policies were purchased by the husband of the complainant in

the year 2007 & 2010. Unfortunately he died on 26.06.2010 due to sudden heart attack. The complainant

being the nominee in the said policies applied for payment of death claim which was repudiated on the

ground of suppression of material fact. Hence, being aggrieved he approached this forum for redressal.

The insurer on the other hand submitted SCN stating that policy no. 588063628 was issued under money

plus plan. As per the policy terms and conditions of this plan, in case of death of LA death claim will be

higher of Sum Assured or the fund value of units held in policyholder’s account at the date of booking

liability. Accordingly insurer has sent discharge forms and NEFT mandate forms to the policyholder which

has not been submitted. Regarding policy no. 598011373, the claim was an early claim and after investigation

it was found that LA was diagnosed as a patient of RHD, MS, PAH, AF, CCF and he was suffering from this

disease since last 3 years. As these material fact were suppressed at the time of proposal the claim was

repudiated.


a) Complainant’s argument:- The Complainant stated that the above mentioned policies were purchased by

her husband in the year 2007 & 2010 respectively from the present insurer. Unfortunately he died on

26.06.2010 due to sudden heart attack. The complainant being the nominee in the said policies applied for

payment of death claim in respect of both the policies which was repudiated on the ground of suppression of

material fact.

b) Insurers’ argument:- The insurer on the other hand pleaded that policy no. 588063628 was issued under

money plus plan. As per the policy terms and conditions of this plan, in case of death of LA death claim will

be higher of Sum Assured or the fund value of units held in policyholder’s account at the date of booking

liability. Accordingly insurer has sent discharge forms and NEFT mandate forms to the policyholder which

has not been submitted yet. Regarding policy no. 598011373, the claim was an early claim and after

investigation it was found that LA was diagnosed as a patient of RHD, MS, PAH, AF, CCF and he was

suffering from this disease since last 3 years. As these material fact were suppressed at the time of proposal

the claim was repudiated.







submissions made by both the parties it was observed that the insurer is ready to pay the death claim

amount in respect of policy no. 588063628 which is a money plus policy. As per the terms and conditions of

the policy, in case of death of LA, death claim amount will be higher of Sum Assured or the Fund Value of

units held in policyholder’s account on the date of booking the liability. So in this case, the claimant was

advised to submit required papers along with NEFT mandate for payment of death claim amount. However

as death had occurred in June 2010, and the insurer has delayed the payment of death claim for around 10

years, in this case the claim amount would be paid with interest from the date of booking the liability. So far

as second policy i.e policy no. 598011372 is concerned, death occurred just after 2 months from the date of

commencement of the policy for which insurer went of an investigation. The insurer did not submit any

report of the investigator to substantiate it’s repudiation of claim. The claim was repudiated only on the

basis of claim form B and B1 which was executed by the Medical Officer of DHH Balasore. According to this

report, the patient was diagnosed as suffering from RHD (Rheumatic Heart Disease), MS (Mitral Stenosis),

CCF( Chronic Cardia Failure) etc. But there is no such prescription from any Doctor showing that he

received any definite treatment under any medical practitioner for the above ailment. As per the son of the

DLA, his father was a strong and stout person. As he was a teacher by profession regularly he was going to

his school through a bicycle which is around 20 km distance from his home. He had never seen him suffering

from any such diseases as claimed by the insurer. So there is no documentary evidence with the insurer to

show that the policyholder was receiving treatment as an in-door patient in any Hospital/Nurshing Home. In

view of the above, this forum is of the opinion that the insurer was not fair to repudiate the claim on the

ground of misstatement or withholding any material information regarding health. Hence, the repudiation

order of the insurer being unjust, is to be set aside and claim is to be admitted for full Sum Assuredf.





Ombudsman.

b. As per rule 17(7) the complainant shall be entitled to such interest at a rate per annum as

specified in the regulations framed under the Insurance Regulatory and Development Authority

of India Act 1999, from the date the claim ought to have been settled under the regulations, till

the date of payment of the amount awarded by the Ombudsman


the Insurers.



INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE





CASE OF (Smt. Ranjita Jena Vs. LIC of India Cuttack DO)



1. Name & Address of the Complainant Mrs. Ranjita Jena, At/Po- Sirapur,

Via- Chakabarapur, Balasore

2. Policy No:

Type of Policy


586552433

Life

12.10.2006

AWARD


the parties during the course of hearing, it is awarded that i) in respect of policy no. 588063628

the complainant has to submit all required papers along with NEFT mandate with the insurer

for settlement of death claim with interest, & ii) in respect of policy no. 598011372, the insurer

has to admit the claim and pay the full sum assured of the policy to the claimant as full and

final settlement of the claim.




Late Rajendra Kumar Jena

- do-











13(1)(b)



For the Complainant Ranjita Jena




17) Brief Facts of the Case:- The above said policy was purchased by the husband of the complainant on

12.10.2006 from the present insurer. Unfortunately he died on 05.05.2017 due to heart attack. The

complainant being the nominee in the said policy applied for payment of death claim which was repudiated

on the ground of suppression of material fact. As per the insurer, the LA was suffering from HTN &

Diabetes prior to the revival of the policy. Hence, being aggrieved she approached this forum for redressal.

The insurer on the other hand submitted SCN stating that although the policy had commenced on

12.10.2006, it was revived on 04.05.2017 and death took place on 05.05.2017. As it was a case of early claim,

the insurer entrusted the case for investigation. After investigation it was found that the deceased was

already admitted in Kalinga Hospital Bhubaneswar on 27.04.2017 for various complicacy HTN, Type2 DM,

CLD-AKI-HD, Sepsis- Septic shock which he had suppressed at the time of revival. Thus it was a deliberate

attempt to withheld material information regarding his health condition. It means the LA was very much

aware regarding his death for which the policy was revived and death occurred on just next day of revival.

Hence, the claim was repudiated.


a) Complainant’s argument:- The above said policy was purchased by the husband of the complainant on

12.10.2006 from the present insurer. Unfortunately he died on 05.05.2017 due to heart attack. The

complainant being the nominee in the said policy applied for payment of death claim which was repudiated

on the ground of suppression of material fact. As per the insurer, the LA was suffering from HTN &

Diabetes prior to the revival of the policy.

b) Insurers’ argument:- The insurer on the other hand pleaded that although the policy had commenced on

12.10.2006, it was revived on 04.05.2017 and death took place on 05.05.2017. As it was a case of early claim,

the insurer entrusted the case for investigation. After investigation it was found that the deceased was

already admitted in Kalinga Hospital Bhubaneswar on 27.04.2017 for various complicacy HTN, Type2 DM,

CLD-AKI-HD, Sepsis- Septic shock which he had suppressed at the time of revival. Thus it was a deliberate

attempt to withheld material information regarding his health condition. It means the LA was very much

aware regarding his death for which the policy was revived and death occurred on just next day of revival.

Hence, the claim was repudiated.


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





submissions made by both the parties it was observed that the policy was revived on 04.05.2017 by paying

outstanding premiums from 10.2015 to 10.2016 and death occurred on 05.05.2017. In other words, death

took place just one day after the revival of the policy for which investigation was conducted by the insurer.

After investigation, it was revealed that the DLA was suffering from HTN and Type2 DM prior to the revival

of the policy. The deceased was admitted in Kalinga Hospital, Bhubaneswar on 27.04.2017 and died on

05.05.2017 in the same Hospital. The LA was in the Hospital on the date of revival of the policy. So the

declaration of good health submitted by the DLA was manufactured by some other person fraudulently only

to get the benefit of insurance. The insurer has rightly paid the paid-up value along with the refund of

revival amount to the complainant. Hence, this forum is of the opinion that the complaint is devoid of any

merit and thus is treated as dismissed.





Ombudsman.






the Insurers.



INSURANCE OMBUDSMAN


AWARD


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

PROCEEDINGS BEFORE





CASE OF (Smt. Bishnupriya Mahunta Vs. LIC of India Cuttack DO)


COMPLAINT REF: NO: BHU-L-BHU-A/LI/218/2019-2020

1. Name & Address of the Complainant Mrs. Bishnupriya Mahunta, At- Napanga, Birol

PS- Tangi, Cuttack

2. Policy No:

Type of Policy


596929287

Life

28.06.2015



Late Saroj Mahunta

- do-



6. Reason for repudiation AB rider not opted


8. Nature of complaint Accident benefit not paid






13(1)(b)







17) Brief Facts of the Case:- The above policy was purchased by the husband of the complainant from the

present insurer on 28.06.2015. The said policy was issued under endowment assurance plan. Unfortunately

the LA died on 14.10.2015 due to accident. Being the nominee the complainant applied for payment of death

claim along with accident benefit claim. But the insurer settled the death claim for full sum assured on

30.12.2016 without payment of accident benefit. Hence, being aggrieved she approached this forum for

redressal.

The insurer on the other hand submitted SCN stating that accident benefit is an optional rider in the said

policy which was not opted by the LA at the time of proposal. This is an optional rider for which insurer

charges extra premium. If this benefit is opted for, an additional amount equal to Sum Assured is payable on

death due to accident. But as mentioned in the policy schedule of the policy bond, the said policy was issued

without Accident and Disability benefit. Accordingly accident benefit rider premium was also not included in

the basic premium of the policy. Hence, accident benefit is not payable in the said policy.


a) Complainant’s argument:- The complainant was absent during the course of hearing.

b) Insurers’ argument:- The insurer on the other hand pleaded that accident benefit is an optional rider in

the said policy which was not opted by the LA at the time of proposal. This is an optional rider for which

insurer charges extra premium. If this benefit is opted for, an additional amount equal to Sum Assured is

payable on death due to accident. But as mentioned in the policy schedule of the policy bond, the said policy

was issued without Accident and Disability benefit. Accordingly accident benefit rider premium was also not

included in the basic premium of the policy. Hence, accident benefit is not payable in the said policy.


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





submissions of both the parties it was observed that the Life Assured had opted for accident benefit coverage

in the proposal submitted by him. Further, the underwriting decision of the insurer dated 23.07.2015, also

permits the coverage of accident benefit in the subject policy (Accepted with OR +ABC). But unfortunately

the accident benefit rider premium was not added in the total premium charged by the insurer which seems

to be a clerical mistake. Now the poor complainant can not be penalized for the mistake of the insurer.

Hence, this forum is of the opinion that accident benefit is to be admitted and paid to the complainant with

recovery of additional premium if any.





Ombudsman.






the Insurers.



INSURANCE OMBUDSMAN


AWARD


parties during the course of hearing, it is awarded that Accident Benefit is to be admitted in the

subject policy and paid to the complainant by the insurer with recovery of additional premium

if any.


PROCEEDINGS BEFORE





CASE OF (Mr. Kailash Sahoo Vs. LIC of India Berhampur DO)

COMPLAINT REF: NO: BHU-H-029-1920-0216


1. Name & Address of the Complainant Mr. Kailash Sahoo. S/O- Late Narayan Sahoo

At- Nuagaon, Mahavir Sahi, Po- Champatipur

Via- Itamati, Nayagarh- 752068

2. Policy No:

Type of Policy


574801637

Life

05.09.2013



Late Bimala Dei

- do-

4. Name of the insurer LIC of India Bhubaneswar










13(1)(b)



For the Complainant Kailash Sahoo

For the insurer Daitary Naik



17) Brief Facts of the Case:- The above said policy was purchased by the wife of the complainant on

05.09.2013 from the present insurer. Unfortunately she died on 18.11.2016. The complainant being the

nominee in the said policy applied for payment of death claim . But it was repudiated by the insurer on the

ground of suppression of material fact regarding health.

The insurer on the other hand submitted SCN stating that although the policy had commenced on

05.09.2013, it was lapse due to non-payment of premium and was revived on 25.06.2016. Death of the LA

occurred on 18.11.2016. The complainant submitted all claim papers in the office of the insurer. From the

papers it was found that the LA died from COPD that she was suffering from for last two years. At the time

of revival she had not disclosed this in the DGH submitted by her. Had she disclosed about her illness,

revival would have been denied to her. Hence, the claim was repudiated on the ground of suppression of

material fact.


a) Complainant’s argument:- The complainant stated that the above said policy was purchased by his wife

on 05.09.2013 from the present insurer. Because of her poor financial condition she could not pay the

premium in time for which the policy lapsed. But it was revived on 25.06.2016 by paying all the arrear

premiums. Unfortunately she died on 18.11.2016. The complainant being the nominee in the said policy

applied for payment of death claim . But it was repudiated by the insurer on the ground of suppression of

material fact regarding health at the time of revival.

b) Insurers’ argument:- The insurer on the other hand stated that although the policy had commenced on

05.09.2013, it was lapse due to non-payment of premium and was revived on 25.06.2016. Death of the LA

occurred on 18.11.2016. The complainant submitted all claim papers in the office of the insurer. From the

papers it was found that the LA died from COPD that she was suffering from for last two years. At the time

of revival she had not disclosed this in the DGH submitted by her. Had she disclosed about her illness,

revival would have been denied to her. Hence, the claim was repudiated on the ground of suppression of

material fact.







submissions made by both the parties it was observed that LA was a self employed lady with a very nominal

income. The premium could not be paid in time due to the poor financial condition of the LA as a result of

which the policy got lapsed. But later it was revived by payment of all the arrear dues along with a

declaration of good health. From the Xerox copy of the DGH it was also observed that, the same was not

filled up correctly which was also ignored by the insurer at the time of revival. So there was no evidence of

foul play on the part of the deceased life assured. Death occurred just after 5 months from the date of

commencement of the policy for which insurer went for an investigation. The insurer did not submit any

report of the investigator to substantiate it’s repudiation of claim. The claim was repudiated only on the

basis of claim form B which was executed by the Medical Officer of DHH Nayagarh. According to this

report, the patient was diagnosed as suffering from COPD for last 2 years. But there is no such prescription

from any Doctor showing that she received any definite treatment under any medical practitioner for the

above ailment. So there is no documentary evidence with the insurer to show that the policyholder was

receiving treatment as an in-door patient in any Hospital/Nurshing Home prior to the date of revival. In view

of the above, this forum is of the opinion that the insurer was not fair to repudiate the claim on the ground of

misstatement or withholding any material information regarding health. Hence, the repudiation order of the

insurer being unjust, is to be set aside and claim is to be admitted for full Sum Assured.





Ombudsman.

AWARD


parties during the course of hearing, it is awarded that the insurer has to admit the claim and pay

the full sum assured of the policy to the claimant as full and final settlement of the claim.







the Insurers.



INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE





CASE OF (Mr. Himansu Bhusan Parida Vs. LIC of India Berhampur DO)

COMPLAINT REF: NO: BHU-H-029-1920-0172


1. Name & Address of the Complainant Mr. Himansu Bhusan Parida, At/Po- Lenkudipada

Dist- Nayagarh 752070

2. Policy No:

Type of Policy


572171914

Life

28.01.2010



Late Bhagaban Parida

- do-

4. Name of the insurer LIC of India Berhampur DO










13(1)(b)



For the Complainant Himansu Bhusan Parida

For the insurer Daitary Nayak



17) Brief Facts of the Case:- The above said policy was purchased by the father of the complainant on

28.01.2010 from the present insurer. Unfortunately he died on 05.07.2012 due to Haematemesis and shock.

After his death the claimant being the nominee in the said policy applied for payment of death claim. But till

date the claim amount has not been paid. Hence, being aggrieved he approached this forum for redressal.

The insurer on the other hand submitted SCN stating that the DLA was suffering from HTN, PTDM and

Chronic kidney failure and transplantation was done on 07.07.2000. He was under treatment regularly. The

complainant had also submitted some papers to the insurer relating to DLA’s past treatment in Apollo

Hospital, Hyderabad dated 08.06.2000. He did not disclose these treatment particulars at the time of

proposal. Had it been disclosed, insurer’s underwriting decision would have been different. As the LA had

suppressed some material fact regarding his health, the claim was repudiated.


a) Complainant’s argument:- The complainant stated that the above said policy was purchased by his father

on 28.01.2010 from the present insurer. The said policy was procured by deducting the premium from one

old policy of the DLA which matured in the year 2010. Unfortunately he died on 05.07.2012 due to

Haematemesis and shock. After his death the claimant being the nominee in the said policy applied for

payment of death claim. But till date the claim amount has not been paid.

b) Insurers’ argument:- The insurer on the other hand pleaded that the DLA was suffering from HTN,

PTDM and Chronic kidney failure and transplantation was done on 07.07.2000. He was under treatment

regularly. The complainant had also submitted some papers to the insurer relating to DLA’s past treatment

in Apollo Hospital, Hyderabad dated 08.06.2000. He did not disclose these treatment particulars at the time

of proposal. Had it been disclosed, insurer’s underwriting decision would have been different. As the LA had

suppressed some material fact regarding his health, the claim was repudiated.







submissions of both the parties it was observed that the subject policy was made by the insurer by deducting

the premium amount from the maturity proceeds of an old policy on the life of the DLA. Although he was

suffering from HTN, PTDM and Chronic Kidney Disease, it was suppressed by him at the time of taking the

policy. Even kidney transplant was done on 07.07.2000 and he was under regular treatment. The

complainant had also submitted some papers to the insurer relating to DLA’s treatment in Apollo Hospital,

Hyderabad which was not disclosed at the time of proposal. These are all material facts for the insurer for

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

different. So, the decision of the insurer in repudiating the claim is justified. However, as it is not an act of

fraud, the total premium paid by the DLA in respect of the subject policy is to be returned by the insurer.



AWARD


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

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

the complaint..




Ombudsman.






the Insurers.



INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE





CASE OF (Mrs. Sabita ParidaVs. LIC of India Sambalpur DO)



1. Name & Address of the Complainant Mrs. Sabita Parida, W/O- Late Subal Kumar Parida

Qtrs- A/106, Sector-3, Rourkela- 769006

2. Policy No:

Type of Policy


590036822, 591108062,591491927,592121188 , 592124365 &

592124626

Life



Late Subal Kumar Parida

- do-

4. Name of the insurer LIC of India Bhubaneswar DO




8. Nature of complaint Non-payment of Accident claim






13(1)(b)




For the insurer Jubaraj Muna



17) Brief Facts of the Case:- The Life Assured was an employee of Rourkela Steel plant and met with an

accident on 11.05.2017 while he was on duty. Immediately he was admitted in IGH, RSP and underwent

treatment till 20.05.2017. But unfortunately he died on 20.05.2017. The DLA had five policies and death

claim was settled in all these policies and these were settled as normal claim. But accident benefit is not paid

till date. Hence, being aggrieved he approached this forum for redressal.

The insurer on the other hand submitted SCN stating that certain requirements were called for like 1)

Copies of FIR, 2) Police Inquest Report, 3) Police Final Report and 4) Post Mortem Report to ascertain the

death occurred due to accident. For want of the above basic requirements this case is pending for decision to

pay the accident benefit claim.


a) Complainant’s argument:- The complainant was absent during the course of hearing.

b) Insurers’ argument:- During the course of hearing the insurer stated that it has already admitted and

paid the accident claim in respect of all the six policies as per detailed below.

Policy no Amount paid Date of payment

592124365 Rs.125000 21.01.2020

591108062 Rs.50000 23.12.2019

591491927 Rs.51000 23.12.2019

592121188 Rs.100000 23.12.2019

590036822 Rs.75000 23.12.2019

592124626 Rs.125000 23.12.2019

Hence, the complaint should be dismissed.


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




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

made by the insurer, it was observed that the accident benefit in respect of all the six policies is admitted

and paid to the complainant on the dates as mentioned above. Being satisfied with the response of the

insurer, the complainant also did not attend the hearing. Hence, this forum is of the opinion that the

complaint is to be treated as disposed of.





Ombudsman.

AWARD


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






the Insurers.



INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE





CASE OF (Mr. Gurubaria Bhoi Vs. Bajaj Allianz Life Insurance co. ltd)



1. Name & Address of the Complainant Mr. Gurubaria Bhoi, C.O- Panchayat Nodal UP School

At- Nuapara, Po/Via- Balipatna, Khurda- 752102

2. Policy No:

Type of Policy


0322242271

Life

18.03.2015



Mrs. Bijayalakshmi Bhoi

- do-

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




8. Nature of complaint Non- payment of death claim

9. Amount of Claim Rs.839228/-


11. Amount of relief sought Rs.839228/-



13(1)(d)



For the Complainant Gurubaria Bhoi

For the insurer Saswat Banerjee



17) Brief Facts of the Case:- The above mentioned policy was purchased by the wife of the complainant from

the present insurer on 18.03.2015. It was a group insurance policy which was issued against a Housing loan

of Rs.1000000/- availed by the wife of the complainant from Utkal Cooperative Banking Society Ltd.

Bhubaneswar. The life insurance coverage was made for the above loan amount through the above master

policy. Unfortunately his wife died on 20.11.2017. Being the legal heir of the DLA the complainant applied to

the insurer for liquidation of outstanding loan of Rs. 839226/- which was rejected by the insurer on the

ground that she had suppressed some material fact regarding her health. Hence, being aggrieved he

approached this forum for redressal.

The insurer on the other hand submitted SCN stating that the LA had availed a housing loan of Rs.1000000/-

from the Utkal Co-operative Banking Society on 18.03.2015. In order to assure the loan amount, the LA

submitted a duly signed proposal form on 31.03.2015 to avail coverage under Group Credit Protection plus

policy. But, she was well aware that she was suffering from Hypertension and stage V Chronic kidney

disease since 28th February 2015 which is prior to the commencement of the policy. She also underwent a

renal transplant in the year 2016 . As the above health condition was a material fact which was suppressed

by the LA at the time of proposal, the claim was repudiated.


a) Complainant’s argument:- The complainant stated that above mentioned policy was purchased by his wife

from the present insurer on 18.03.2015. It was a group insurance policy which was issued against a Housing

loan of Rs.1000000/- availed by the wife of the complainant from Utkal Cooperative Banking Society Ltd.

Bhubaneswar. The life insurance coverage was made for the above loan amount through a master policy.

Unfortunately his wife died on 20.11.2017. Being the legal heir of the DLA the complainant applied to the

insurer for liquidation of outstanding loan of Rs. 839226/- which was rejected by the insurer on the ground

that she had suppressed some material fact regarding her health.

b) Insurers’ argument:- The insurer on the other hand pleaded that the LA had availed a housing loan of

Rs.1000000/- from the Utkal Co-operative Banking Society on 18.03.2015. In order to assure the loan

amount, the LA submitted a duly signed proposal form on 31.03.2015 to avail coverage under Group Credit

Protection plus policy. But, she was well aware that she was suffering from Hypertension and stage V

Chronic kidney disease since 28th February 2015 which is prior to the commencement of the policy. She also

underwent a renal transplant in the year 2016 . As the above health condition was a material fact which was

suppressed by the LA at the time of proposal, the claim was repudiated.







submissions of both the parties it was observed that the subject policy was purchased by the DLA to insure

the housing loan amount of Rs.1000000/- availed by her from Utkal Cooperative Banking Society. The policy

was issued by the insurer on the basis of the proposal paper submitted by her and the declaration made by

her in regard to her health conditions. Nowhere she had disclosed that she was suffering from hypertension

and infection or any other disorder of the kidney. As per the prescription of Dr. Nitish Kumar Mohanty, Sr.

consultant Nephrology, dated 28.02.2015, she was a known case of Hypertension and CKD. These were all

material facts for the insurer for consideration of insurance on her life. As per the terms and conditions of a

policy , if the life assured provides any inaccurate or false statement which is material to the said policy, then

the said policy will be treated as cancelled and all the premium paid in respect thereof shall be forfeited.

Hence, this forum is of the opinion that the insurer has rightly repudiated the claim in respect of the said

policy and thus the complaint is to be treated as dismissed.

AWARD


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





Ombudsman.






the Insurers.



INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF CHANDIGARH

(UNDER INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – Dr. D K Verma

Case of Ms Charan Kaur V/S HDFC Standard Life Insurance Co. Ltd.

COMPLAINT REF: NO: CHD-L-019-1920-0975


Complainant

Ms Charan Kaur

W/O Sh. Prem Singh, Village- Kambala,

VPO- Dharamgarh, SAS Nagar, Mohali,

Punjab-140306

2. Policy No:

Type of Policy


18752779

HDFC life classic plan



Prem Singh

4. Name of the insurer HDFC Standard Life Insurance Co. Ltd.




8. Nature of complaint Death Claim

9. Amount of Claim NA


11. Amount of relief sought Death Claim, 10 lakh


Rule no:

13.1(b)


For the Complainant Son

For the insurer Shri Arpit Higgins, Manager(Legal&Comp)

Shri Gurpreet Singh, Dy Manager(Legal)

14 Complaint how disposed Agreement

15 Date & Place of Hearing 05.02.2020/Chandigarh


On 24.09.2019 Ms Charan Kaur, had filed a complaint in this office against HDFC Standard Life

Insurance Company. The complainant alleged that her husband had a HDFC life policy with

premium 1 lakh. He expired on 04.11.2017. They submitted the claim papers with the company

and received Rs 1,11000 as death claim payment. But as per policy conditions she was to receive

10 times the premium amount as death claim payment. She made a detailed complaint to

company but was denied any more payment. Hence, feeling aggrieved, she has approached this

forum to seek justice.

17) The Insurance Company agreed to pay the full death claim under the policy bearing number

18752779 to the nominee.

18) The Company’s offer is accepted by the Complainant.

19) Accordingly, an agreement was signed between the Company and the complainant on

05.02.2020.

20) The complaint is closed with a condition that the company shall comply with the agreement

and shall send a compliance report to this office within 30 days of receipt of this order for

information and record.

To be communicated to the parties.

Dated at Chandigarh on 5th day of February, 2020.

Dr. D.K.VERMA

INSURANCE OMBUDSMAN




Case of Ms Seema Devi V/S HDFC Standard Life Insurance Co. Ltd.



Complainant

Ms Seema Devi

w/o Sh Ganga Ram, VPO- Andhop, Tehsil-

Hathin, Palwal, Haryana-121106

2. Policy No:

Type of Policy


19000804

Classic Assure Plus



Sh Gangaram





8. Nature of complaint Non Payment of death claim, Rs 8 lakhs.



11. Amount of relief sought Death Claim


Rule no:

13.1(b)


For the Complainant Self

For the insurer Shri Arpit Higgins, Manager(Legal & Comp)


14 Complaint how disposed Award



On 24.04.2019, Ms Seema Devi w/o Sh Gangaram had filed a complaint in this office against HDFC

Standard Life Insurance Company about nonpayment of death claim of her husband’s policy bearing

number 19000804. The complainant alleged that the claim has been rejected as the income and

occupation details disclosed in the proposal form were found to be false as per the company

investigation. The company has paid the fund value of the policy. According to the complainant her

husband died of heart attack on 04.03.2017. The deceased owned a tent renting shop. In addition to this

he used to sell stone idols brought from Alwar, Rajasthan. His annual income was 3.5 - 4 lakhs and she

being illiterate was not aware whether she filed his ITR or not. In support of her claim, statements of the

sarpanch and councilor have been enclosed.


a) Complainant’s argument:

The complainant reiterated the contents of her complaint and said that her husband died of heart attack

in 2017. She being just 8th pass and has three children aged 9, 10 and 12 years old.

b) Insurers’ argument:

The representative of the Company informed that the policy bearing number 19000804 was issued on

05.02.2017 for a premium of Rs. 15000/= half yearly to be paid for 10 years for a sum assured of

Rs 8 lakhs. The life assured died on 04.03.2017 i.e after a period of 1 month from the date of the

policy. This being an early claim was investigated and it was found that the life assured had not

disclosed his correct income and occupation. It was revealed that the complainant was a BPL card

holder. It was the Asha worker’s statement and record revealed that the life assured Ganga Ram

alias Ganga Charan died on 01.04.2016. Copy of statement and register was furnished as proof by

the company. Accordingly the death claim was repudiated and the premium refunded since the

contract was void ab initio.

18) The following documents were placed for perusal :-

a) Complaint to the Company

b) Reply of the Insurance Company

19) Result of personal hearing with both parties (Observations & Conclusion)

I have examined the various documents available in the file including the copy of the complaint,

Annexure-VI and the contents of the SCN filed by the Insurance Company. It is evident from the

documents and submission of both the parties that the complainant died after 1month from the

issuance of the policy. The only objection that the Company has raised in the repudiation letter

dated 31.03.2019 is that the income and occupation declared by the Life Assured in the proposal

form were false. In fact, this objection should have been raised at the time of acceptance of risk and

now, at this stage of payment of claim, the Insurer cannot take shelter under the objection of

incorrect income. The copy of BPL card dated 20.02.2007 cannot be the sole basis for repudiation

of claim. Further, the Insurance Company has produced the Asha worker’s record wherein the name

of the deceased is Ganaga Charan and the age mentioned is 40 years. The record although has the

same fathers name and other particulars but does not even mention “alias Ganaga Charan” though

the same has been put in the written statement. Also the age as per proposal form, ration card and

other record is approximately 32 years which is quite different from what has been stated in the

Anganwadi record. Moreover the company did not produce any evidence of his actual income. As

such the decision of the company to repudiate the claim is not justified.

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

parties during the course of hearing, the Insurance Company is directed to pay death claim

under policy bearing number 19000804.

Hence, the complaint is treated as closed.

The attention of the complainant and the Insurer is hereby invited to the following provisions of


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

with the award within 30 days of the receipt of the award and intimate compliance of the

same to the Ombudsman.

Dated at Chandigarh on 28th day of February, 2020

Dr. D K Verma

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, CHANDIGARH (UNDER INSURANCE OMBUDSMAN RULES, 2017)

INSURANCE OMBUDSMAN-Dr. D.K. VERMA

Case of Mr. Amar Dutt Sharma Vs SBI Life Insurance Co. Ltd.

CASE NO-CHD-L-041-1920-1115


Complainant

Mr. Amar Dutt Sharma

S/o Shri Gyan Dutt, R/o House No.- 79, Ward No.- 2,

Near Biroja, Factory Nahan (Banog),

Distt.- Sirmaur, Sirmaur, Himachal Pradesh- 173001

Mobile No.- 9459741286

2. Policy No: DOC

Type of Policy


70000018310 / 20-09-2017

SBI Life- Rinn Raksha



Mrs. Sushil Bhardwaj

4. Name of the insurer SBI Life Insurance Co. Ltd.



7. Date of receipt of the Complaint 31-10-2019

8. Nature of complaint Non -Settlement of death claim

9. Amount of Claim Sum assured Rs. 15 lac

10. Date of Partial Settlement Na

11. Amount of relief sought Sum assured Rs. 15 lac


Rule no: Insurance

Ombudsman Rules, 2017

13 1 (d)

13. Date of hearing/place 17-02-2020 / Chandigarh



For the insurer Ms.Shagun Bhalla



17. Brief Facts of the case:

On 31-10-2019, Mr. Amar Dutt Sharma had filed a complaint about repudiation of death of

his deceased wife against SBI Life Insurance Co. Ltd. in respect of policy bearing no.

70000018310. The claim was rejected on the ground of pre existing diseases, i.e concealment of

material facts.

18. Complainants argument :

In personal hearing Mr. . Amar Dutt Sharma, the complainant reiterated the contents of

complaint and submitted that his wife unfortunately died on 01-05-2019 due to heart attack.

He submitted that his wife had taken housing loan from SBI and the loan was secured under the

stated policy for Rs. 15 lac and premium was paid update. He added that the insurer had

repudiated the death claim of his wife alleging that she had concealed the material facts about

her health that she was under treatment from 2011 onwards from various hospitals. The

decision of repudiation was informed to complainant by the insurer vide letter dated

29.06.2019. He further stated that his wife was healthy at the time of taking policy and also

was in good health at the time of taking policy. The complainant also submitted that insurer

had not asked any question about previous illness at the time of taking policy; however he

accepted about his wife’s previous illness treatment from various hospitals and also informed

that she was govt. employee.

19. Insurers’ argument:

The insurance company in personal hearing & in SCN submitted that the company received claim

intimation under the said insurance cover from the complainant on 24-05-2019 regarding

unfortunate death of his wife on 01.05.2019. However, the same was repudiated as there was

suppression of illness i.e. Diabetes Mellitus II, Hypertension, Cerebro Vascular Accident,

Middle Cerebral Artery infract and Hemiparesis prior to the date of commencement of the

insurance cover. Hence no claim is payable under the said insurance cover as per the terms and

conditions of the policy. As per treatment papers dated 03-07-2011, 22-07-2011, 16-08-2011,

17-08-2011, 23-03-2012, 14-05-2012, 01-06-2012, 16-06-2012, 04-07-2012 and OPD card

dated 27-11-2013 of Postgraduate Institute of Medical Education and research, Chandigarh, it is

mentioned that the DLA was a case of Hypothyroidism, HTN, MCA Infaract in February 2011,

taking physiotherapy, DM II. As per the medical certificate of cause of death dated 01-05-2019

issued by Shri Sai Multi Speciality Hospital, Nahan, the DLA was suffering from DM Type II,

HTN, AKI, Hypothyroidism, Pericarditis, Pleural Effusion, Ascitis, Respiratory Distress,

Anaemia. The company conducted the investigation after the receipt of the claim intimation

from the complainant. It is the duty of the proposer to disclose all the material facts in the

membership form or during his lifetime regarding his health, habits, etc to the insurance

company as the insurance contract is a contract of “Utmost Good Faith’. If it is found that DLA

availed insurance cover suppressing the material facts, the insurance company is well within its

rights to repudiate the claim.

20. The following documents were placed for perusal:

a) Complaint to the Company b) Copy of policy document

c) Annexure Vl-A d) Reply of the Insurance Company

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

On hearing both the parties and examining the various documents available in the file it is evident that

the complainant’s wife had taken a policy for sum assured Rs. 15 lac- with date of commencement as

20.09.2017 and the life assured died on 01.05.2019 i.e. within two years of taking the policy. The investigation conducted by the Insurance Company and the papers submitted by the Insurance

Company revealed that the deceased life assured had taken treatment prior to policy .As per

treatment papers dated 03-07-2011, 22-07-2011, 16-08-2011, 17-08-2011, 23-03-2012, 14-05-

2012, 01-06-2012, 16-06-2012, 04-07-2012 and OPD card dated 27-11-2013 of Postgraduate

Institute of Medical Education and research, Chandigarh, it is mentioned that the DLA was a

case of Hypothyroidism, HTN, MCA. The fact about said ailment and hospitalization was not disclosed at the time of taking policy. Since, it is a clear case of suppression of material facts and against the principle of Uberrima fides (Utmost good faith) the Insurance Company has rightly

repudiated death claim as per terms & conditions of the policy. The provision of section 45 of

Insurance laws [Amendment] Act, 2015 states that in case claim under a policy is repudiated on

the grounds of misstatement or suppression of material facts, the premium collected under the

policy till the date of repudiation is to be refunded to the nominee/ claimant/ assignee/ legal

heirs, as the case may be, with in a period of ninety days from the date of such repudiation., , in

this case the company has already refunded premium collected under the policy as per section

45.

ORDER

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

parties during the course of personal hearing, the complaint is dismissed.


Dated at Chandigarh on 17.02.2020

D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE



Case of Mrs. Radhika Parashar Vs SBI Life Insurance Co. Ltd.

CASE NO-CHD-L-041-1920-1029


Complainant

Mrs. Radhika Parashar

W/o Sh. Yash Parashar, 5, Surya Enclave, Amloh

Road, Khanna, Punjab- 141401

Mobile No.- 7837103807

2. Policy No: DOC

Type of Policy


7006498680 & 7006498677 / 10-03-2016

SBI Life- Rinn Raksha Plan

Premium- 7118 & 2107



Mr. Yash Parashar





8. Nature of complaint Non-settlement of death claim/ less amount settled

9. Amount of Claim Sum assured Rs. 12 lac & 8 lac


11. Amount of relief sought Sum assured Rs. 12 lac & 8 lac


Rule no: Insurance


13 1 (d)








On 14-10-2019, Mrs. Radhika Parashar filed a complaint about non-settlement of death claim

against SBI Life Insurance Co. Ltd. in respect of policy nos. 7006498680 & 7006498677

issued under master policy no. 70000011705 for sum assured of Rs. 12 lac & 8 lac respectively.


In personal hearing Mrs. Radhika Parashar , the complainant reiterated the contents of

complaint and submitted that her husband unfortunately died on 16-09-2018. She submitted

that her husband had taken housing loan from SBI and the loan was secured under the stated

policies for Rs. 12 lac & 8 lac. She added that the insurer had repudiated the death claim of

her husband under policy no. 7006498677 for 8 lac sum assured, on the ground that policy

was in lapsed condition at the time of death and renewal premium had not been deposited. The

decision of repudiation was informed to complainant by the insurer vide letter dated

02.01.2019. She added that premium of the policies were being deducted from his husbands

bank a/c and was in the impression that premium amounts being regularly deducted as per

instructions. She also informed that SBI life has settled death claim under policy no.

7006498680 for 12 lac sum assured after representing the case in grievance redressal cell.


The insurance company in personal hearing & in SCN submitted that the company received claim

intimation dated 08-11-2018 under the said insurance cover from the complainant. As per the

claim intimation received. Mr. Yash Parashar is reported to have died on 16-09-2018. The

renewal premium due on 10-03-2017 and onwards were not received by the company due to

which the insurance cover lapsed and hence, the claim was rejected on 02-02-2019 due to

lapsation of insurance cover as on date of death of life assured. The paid up value of Rs. 2,

65,648/- and Rs. 1, 48.393/- has been paid vide cheque nos. 322098 and 322099 dated 27-12-

2018 respectively. Further, a representation was received from the complainant in February

2019 and it was put up before the claim review committee which was headed by retired High

Court Judge. In the representation letter, the complainant alleged that the Deceased was

maintaining balance in the account for deduction of premium. The balance amount was only Rs.

8471/- which was not sufficient to pay renewal premiums for both the insurance cover. The

deceased had opted for a “Self Paid” mode only for payment of renewal premiums and the

company had no contractual obligation to deduct the account of the deceased towards renewal

premium. As there was account balance of Rs. 8471/- on 10-03-2017, as a special case, even

though the company in not contractually liable to settle the claim, the claim under LAN No.-

65251531306 was settled considering the same being the higher sum assured. Accordingly, an

amount of Rs. 11, 01,534/-has been paid. The death claim under LAN no. 65249412577 &

policy no7006498677 for which the premium payable amount was Rs. 2107/- was not settled as

there was insufficient balance in the account. The DLA had opted the premium payment option

as “Self Paid”. It is the responsibility of the life assured to pay the premium and to keep the

insurance cover in force. The company did not receive the renewal premiums due on 10-03-

2017 and onwards and hence the insurance covers lapsed with effect from 10-03-2017.




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

On hearing both the parties and examining the various documents available in the file it is evident that the complainant’s husband had taken two policies for sum assured of Rs. 12 lac & 8 lac to cover the

housing loan. The due premiums under polices have not been paid since 03/2017. The deceased had

opted for a “Self Paid” mode for payment of renewal premiums. It is also observed from bank

statement that the balance amount was only Rs. 8471/- which was not sufficient to pay renewal

premiums for both the policies i.e. Rs.7118 & Rs. 2107 respectively, on 10.03.2017 [due date of

policies] however, insurance company had reviewed the case in claim review committee and

paid death claim under higher sum assured policy no 7006498680 for 12 lac having premium

amount Rs.7118/- Since the balance in a/c was insufficient to cover the premium under policy

no. 7006498677, neither produced any documentary evidence having paid the premium amount,

the decision taken by insurer seems to be correct as per term & conditions of the policy.

Moreover the insurer has also paid Rs. 1, 48.393 as paid up value under the policy no.

7006498677.

ORDER


parties during the course of personal hearing, the complaint is dismissed. Hence, the complaint is

treated as closed.


D.K. VERMA

INSURANCE OMBUDSMAN

PROCEEDINGS BEFORE



Case of Mrs. Asha Rani Vs SBI Life Insurance Co. Ltd.

CASE NO-CHD-L-041-1920-1236


Complainant

Mrs. Asha Rani

W/o Late Shri Sanjay Kumar, House No.- D-351/29,

R/o Shastri Market, Balmiki Basti, Thanesar,

Distt.- Kurukshetra, Haryana-0

Mobile No.- 8708364731

2. Policy No: DOC

Type of Policy


1N052976804 / 09-05-2016 Monthly

Smart Money Back Gold Plan



Mr. Sanjay Kumar

Mr. Sanjay Kumar






9. Amount of Claim Sum assured Rs. 12 lac & 8 lac


11. Amount of relief sought Rs. 12 lac


Rule no: Insurance


13 1 (d)





15. Complaint how disposed Award



On 14-11-2019, Mrs. Asha Rani had filed a complaint about repudiation of death claim against

SBI Life Insurance Co. Ltd. in respect of policy bearing no. 1N052976804. The premium

under the policy was deposited up to 09. 01.2019. The date of death is 27.02.2019. Premium

payment frequency is monthly, how the premium has been deposited is not known, i.e. auto

debit through bank or on counter payment. Premiums has been regularly paid expect one

premium before death. If auto debit, bank statement of deceased life assured is not available,

previous debit entries or premium deposited statement/ history is not available. The deceased

life assured was JBT. i.e. govt. employee.


In personal hearing Mrs. Asha Rani , the complainant reiterated the contents of complaint

and submitted that her husband unfortunately died on 27.02.2019. She submitted that her

husband had taken policy for Rs. 12 lac with monthly premium. She added that the insurer had

repudiated the death claim of her husband under policy no. 1N052976804 for 12 lac sum

assured, on the ground that policy was in lapsed condition at the time of death and renewal

premium due for 09.02.2019 had not been deposited. The decision of repudiation was informed

to complainant by the insurer vide letter dated 09.07.2019. She added that premium of the

policies were being deducted from his husbands bank a/c and was in the impression that

premium amounts being regularly deducted as per instructions. She also submitted that her

income is very low as deceased husband was only earning person in her family. She further

submitted that responsibility of looking after children & old age in- laws are big financial

problem for her.


The insurance company in personal hearing & in SCN submitted that the company issued a SBI Life

Smart Money Back Gold Policy bearing no 1N052976804 in the name of Mr. Sanjay Kumar

with date of commencement 09-05-2016. The company received initial premium and renewal

premium till due date 09-01-2019. The renewal premium for the due date 09-02-2019 was not

received by the company and hence the policy lapsed. The DLA is reported to have died on

27.02.2019. It is specifically denied that an amount of Rs. 9,205/- was paid as yearly premium

under the policy as mentioned in the said complaint. The monthly premium due under the policy

was Rs. 9,539/-. In the instant case the company has not received 3 full policy years’ premiums

under the said policy and hence no paid up value acquired. On the date of death of life assured,

the policy was in lapsed condition hence sum assured is not payable under the policy. In the

personal hearing representative of insurer also submitted bank statement of the deceased life

assured




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

On hearing both the parties and examining the various documents available in the file it is evident that the complainant’s husband had taken a policies for sum assured of Rs. 12 lac. The due premium under policy has not paid for 09.02.2019 and death of the life assured occurred on 27.02.2019 i.e after the

expiry of 15 days grace period provided under the terms & conditions of the policy. The deceased had

opted for a monthly mode for payment of renewal premiums. It is observed from bank statement

that the balance amount in deceased a/c was also not sufficient i.e. less than premium amount.

The complainant did not produce any documentary evidence having paid the premium amount.

It is also fact that deceased life assured has paid regular monthly premium nearly about three

years without any break but unfortunately died on 27.02.2019 when grace period for due

premium on 09. 02.2019 were over. However, looking into circumstances & merit of the case

the insurance company is directed to refund all the premiums collected under the policy.

ORDER


parties during the course of personal hearing, the insurance company is directed to refund all

the premiums collected under the policy without deduction of any charges & without

interest Hence, the complaint is treated as closed.


D.K. VERMA

INSURANCE OMBUDSMAN




Case of Ms Sadhna Goel V/S HDFC Standard Life Insurance Co. Ltd.



Complainant

Ms Sadhna Goel

W/O Late Sh. Rajesh Goel, R K Foundary &

Engg. Works, G T Road, Batala-143505

2. Policy No:

Type of Policy


12879808

Childrens double benefit



Shri Rajesh Goel





8. Nature of complaint Death claim not paid

9. Amount of Claim Death claim


11. Amount of relief sought Rs 276979/- along with interest and damages


Rule no:

13.1(b)


For the Complainant Self along with nephew



14 Complaint how disposed Agreement

15 Date of hearing/place 19.02.2020 / Chandigarh


On 09.08.2019 Ms Sadhna Goel, had filed a complaint in this office against HDFC Standard Life

Insurance Company. The complainant alleged that her husband was insured vide the policy

bearing number 1289808. The policy commenced in April 2009 and the LA died on 06.01.2015.

The company did not pay the death claim so the complainant approached this forum on

30.11.2015. This court ordered the company to decide the case within 15 days of receipt of

documents from the complainant. The complainant has complained that even after this the

company has not honored the order and denied her the claim. She has again appealed for justice.

17) The company has agreed to pay maturity amount along with benefits as per terms and

conditions of the policy.

18) The Company’s offer is accepted by the representative of the Complainant.

19) Accordingly, an agreement was signed between the Company and the representative of the

complainant on 19.02.2020.

20) The complaint is closed with a condition that the company shall comply with the agreement

and shall send a compliance report to this office within 30 days of receipt of this order for

information and record.

To be communicated to the parties.


Dr. D K Verma

INSURANCE OMBUDSMAN




Case of Ms Bimla Devi V/S HDFC Standard Life Insurance Co. Ltd.



Complainant

Ms Bimla Devi

W/O Rajender Kumar, Harmesh Lal, F/O

rajender Kumar, Salwara, Bharwain Road,

Hoshiarpur, Punjab-146001

2. Policy No:

Type of Policy


CP000044

Policy against vehicle loan



Shri Rajender Kumar





8. Nature of complaint Death claim not paid



11. Amount of relief sought Rs 100000/-


Rule no:

13.1(d)


For the Complainant None



14 Complaint how disposed Dismissed in default



On 09.08.2019 Ms Bimla Devi, had filed a complaint in this office against HDFC Standard Life

Insurance Company. The complainant alleged that her husband availed a loan of Rs 53994/- on

14.11.2017 for purchase of Hero Maestro and regular installments are being paid by them. Her

husband expired on 28.07.2018 and loan installment of Rs 2242/- was paid even after death of

her husband. During visit to bank she came to know that the loan amount was insured by the

bank vide policy No. CP000044 dated 15.11.2017 which is valid till 14.11.2020 and premium of

Rs 876/- has been taken from them. Papers pertaining to insurance claim were submitted to the

bank on 02.05.2019 vide registered post received by them on 04.05.2019. Even then the same

were not forwarded to the company by the bank officials. When bank officials did not cooperate

they forwarded the papers directly to Mr. Abhinandan Sharma, Sales development manager,

HDFC life insurance directly through registered post. Again a cancelled cheque and an affidavit

were asked by him which were sent on 29.06.2019. But till date no information has been

received. Since both the bank and the company are not cooperating she has complained to this

office and the banking ombudsman for justice.

17) The company has informed that they have not received claim intimation till date and will process

it as per policy terms only after the receipt of the same.

18) Neither the complainant nor her representatives appeared for the personal hearing on 05.02.2020

and 19.02.2020. The case is thus, dismissed in default and closed.


Dr. D K Verma

INSURANCE OMBUDSMAN




Case of Shri Manveer Singh V/S HDFC Standard Life Insurance Co. Ltd.



Complainant

Shri Manveer Singh

S/O Jagdev Singh, Village- Bari, Tehsil-

Dhuri, Sherpur, Distt- Sagrur, Punjab-

148025

2. Policy No:

Type of Policy


19619372

HDFC life classic assure plus plan



Shri Manveer Singh





8. Nature of complaint Nonpayment of death claim



11. Amount of relief sought Death Claim


Rule no:

13.1(b)


For the Complainant None






On 16.09.2019 Shri Manveer Singh, had filed a complaint in this office against HDFC Standard Life

Insurance Company. The complainant alleged that his father Sh. Jagdev singh was insured vide

policy bearing number 19619372 dated 14.09.2017. He died a natural death on 08.04.2019. Two

premiums of Rs 244617/- each for due 2017 and 2018 were paid under the policy till then. The sum

assured under the policy was Rs 16,74,638/-. After death they deposited the claim papers with the

company. the investigator appointed by the company asked for Rs 20000/- as bribe which was

refused. So, a false report has been submitted by him, wherein he has written that the deseased was

suffering from heart disease. But his father was fit and healthy and never had any kind of

medications or any health problem. He wrote to company but was not heard, hence this complaint.

17) The company has informed that the policy bearing number 19619372 on the life of Jagdev Singh

commenced on 12.09.2017 for a premium of Rs 250000/- and Maturity SA of Rs 13,78,473/- and

was bought after being consented for and on being satisfied with the terms and conditions of the

proposal. The Life assured died on 08.04.2019 i.e after a period of 1 year and 7 months. Since it was

an early claim investigation was done and it was found that the LA had not disclosed his correct pre

proposal medical condition. As per investigation the LA was suffering from Ischemic Heart Disease

for the past two years. Had the same been communicated the proposal would not have been accepted.

18) Neither the complainant nor his representatives appeared for the personal hearing on 05.02.2020



Dr. D K Verma

INSURANCE OMBUDSMAN




Case of Shri Ravi V/S HDFC Standard Life Insurance Co. Ltd.



Complainant

Shri Ravi

S/O Late Sh. Bhagwant Singh Nain, H No

504/U5, TDI City, Kundli(55), Sonipat,

Haryana-131028

2. Policy No:

Type of Policy


PP000070

HDFC classic assure



Shri Bhagwant Singh Nain



6. Reason for repudiation Pre existing condition


8. Nature of complaint Death claim repudiation

9. Amount of Claim Rs 1191437/-


11. Amount of relief sought Payment of death claim


Rule no:

13.1.(e)



For the insurer Shri Arpit Higgins, Manager(Legal & Comp)


14 Complaint how disposed Dismissed

15 Date of hearing/place 19.02.2020 / Chandigarh


On 20.03.2019 Shri Ravi, had filed a complaint in this office against HDFC Standard Life Insurance

Company. The complainant alleged that his father had the policy and paid the premiums regularly. His

father passed away on 27.09.2018 due to brain stroke. He submitted the papers with the company, but got

a repudiation letter informing that the claim is not payable as his father was suffering from a medical

problem prior to the policy which was not disclosed. The complainant has submitted that his father died

of brain stroke which occurs when the supply of blood to brain is interrupted. Within minutes the brain

cell dies. Hence stroke is a medical emergency which my father got on 07.06.2018. He remained on bed

in ICU since then. With the MRI it was found that a clot has been formed in the brain that caused the

problem and the company showed it as a pre existing medical condition. The complainant alleged that his

father had a paralysis attack in May 2015 and he recovered within 2-3 months and since then he was hale

and hearty. He was even working as manager in an automobile company and used to go 150 km every

day.



The complainant reiterated the contents of his complaint and informed that the case is

regarding his father’s death claim. The policy was taken in 2015 and father expired in 2018

due to brain stroke. The policy was as a collateral security for housing loan. His father got a

paralysis attack in 2015 but recovered in 2-3 months. He was perfectly fine later and was

working as manager in Priya Automobiles, Gohana. He used to go to office on scooter and

used to drive approximately 150 kms daily. Had he been not well how he was able to do all the

daily jobs.


The company, vide SCN dated 11.09.2019 has informed that the complainant was covered under a

group policy that commenced on 20.10.2016 for a reducing sum assured of Rs 1191437. Life

assured died on 27.09.2018 after a period of 23 months from the date of commencement. The life

assured has not disclosed his correct pre proposal health condition that he was suffering from

hypertension since last 15 years and had a history of Cerebro Vascular Accident on 13.05.2015.

Hence the contract is void ab initio.

18) The following documents were placed for perusal:-



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

I have examined the various documents available in the file including the copy of the

complaint, Annexure-VI and the contents of the SCN filed by the Insurance Company. The first

hearing was held on 16.09.2019 wherein no one from the complainant side was present. The

complainant vide letter dated 16.09.2019 received on 19.09.2019 informed that he was unable

to attend the hearing due to Shradh of his father and requested rehearing in the case. A

rehearing was scheduled on 13.11.2019 wherein non one from his side was present. Another

hearing date was given for 17.12.2019 but complainant did not attend the same citing his

mother’s illness as the reason. A last opportunity was given to the complainant and a hearing

was fixed for 05.02.2020. On the day of hearing the complainant reached the office after the

hearings scheduled for the day were over. The complainant pleaded for one more opportunity as

he got delayed due to jam on the road. The last and final hearing opportunity was granted and

the hearing was scheduled for 19.02.2020 wherein the complainant sent his cousin as his

representative. During the hearing on 13.11.2019 the complainant confirmed that his father had

a paralysis attack in 2015 and he recovered from the same within 2-3 months. The complainant

was asked to produce the medical papers which he said he has however he did not appear for

any hearing later. The representative on 19.02.2020 denied any knowledge or procession of any

such papers. It is evident from the documents and submission of both the parties that the Life

Assured had a history of Cerebro Vascular Accident on 13.05.2015and was a known case of

hypertension for the past 15 years, which was not declared at the time of proposing for the new

policy. Such health condition has a bearing on the medical underwriting of the proposal. Hence, the

death claim is rightly repudiated in view of Section 45 of Insurance Act, 1938.


Dr. D K Verma

INSURANCE OMBUDSMAN

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

Company during the course of hearing, there is no need for any interference and the

complaint is dismissed.





Case of Ms Madhuchhanda Basu V/S HDFC Standard Life Insurance Co. Ltd.

COMPLAINT REF: NO: CHD-L-019-1920-0929 & CHD-L-019-1920-1005


Complainant

Ms Madhuchhanda Basu

403, Block-B, Mona Greens, Zirakpur,

Punjab-140663

2. Policy No:

Type of Policy


20937026

HDFC life super income plan



Shri Bijit Basu





8. Nature of complaint Death claim repudiation



11. Amount of relief sought Rs 250000/-


Rule no:

13.1(b)



On 18.09.2019 Ms Madhuchhanda Basu, had filed a complaint in this office against HDFC

Standard Life Insurance Company. The complainant alleged that her husband was hospitalized

on 18.07.2019 at PGI Chandigarh. He expired on 24.07.2019 and accordingly the claim was

lodged with the company on 29.7.2019. According to the policy conditions she was to get death

claim as higher of Sum assured on death or 105% of premiums paid. However she got only Rs

28785/- as death claim payment although the surveyor told her that she will get 250000/- towards

settlement of her claim. The complainant has submitted that in a similar policy with LIC of India,

she has got complete amount that too within one month. She has requested that justice be done to

her as her husband was never hospitalized in last 10 years and she belongs to a middle class

family with a single child aged 13 years.

17) The company, vide SCN dated 28.01.2020 has informed that the complainant was covered under

a super income plan that commenced on 05.12.2018 for a sum assured of Rs 202900/-. Life

assured died on 24.7.2019 after a period of 8 months from the date of commencement. The life

assured has not disclosed his correct pre proposal health condition at the time of proposal that

LA underwent Percutaneous Transluminal Coronary Angioplasty (PTCA) in 2007 and suffered

from Respiratory Failure with Acquired Pneumonia likely Fungal with Hodgkin’s Lymphoma

Stage IIB in 2001. Further there was a relapse in 2005 and the LA underwent high Dose

Chemotherapy and stem cell transfusion. Since it is an early death claim and section 45 of

insurance act is applicable.

18) Neither the complainant nor her representatives appeared for the personal hearing on 05.02.2020



Dr. D K Verma

INSURANCE OMBUDSMAN




Case of Mr. Ravi Inder Singh V/S LIC of India



Complainant

Mr. Ravi Inder Singh,

265, College Road, Mullanpur Dakha,

Distt. Ludhiana (Punjab).147110

Mobile No. 9779327318

2. Policy No:

Type of Policy


301700453/04.11.2007

Amulaya Jeevan, SA 25 LAC

30 Years



Gurinder Singh

Gurdev Singh Tattla (Father ) Nominee

4. Name of the insurer LIC of India


6. Reason for repudiation Lapsed


8. Nature of complaint Death Claim Denied

9. Amount of Claim 25,00,000/-


11. Amount of relief sought 25,00,000/-


Rule no:

13.1(b)

13. Date & Place of Hearing 24.02.2020/Chandigarh


For the Complainant Col. A S Sandhu (Father-in-law)

For the Insurer Ms. Tripta Sharma (AO)


16. Brief Facts of the Case:

On 14.10.2019, Mr. Ravi Inder Singh had filed a complaint in this office against LIC of India

alleging that the Insurance Company has denied the death claim under policy no.301700453 on

the life of his late brother Sh. Gurinder Singh. The complainant has stated that his brother died on

01.01.2019 and the Insurance Company denied the claim on the ground that premium due on

04.11.2018 was not paid hence the policy lapsed and nothing is payable as per policy conditions.

The Complainant has stated that as per proposal forms his brother had taken the policy on

06.12.2007 with date backing from 28.11.2007 but the LIC by mistake started the policy from

04.11.2007and was taking the premiums in advance for 11 years. The complainant has further

submitted that if the DOC of the policy was 15.12.2007 (date of First Premium Receipt) the death

claim would have become payable. Hence feeling aggrieved with the Insurance Company he has

approached this forum to seek justice.



Mr. A.S Sandhu (father in law) of the complainant duly authorized appeared for personal

hearing as the complainant was out of country. Mr. Sandhu reiterated the contents of the

complaint and told that if the DOC of the policy was 15.12.2007 (date of First Premium

Receipt) the death claim would have become payable. He also informed that the life assured died

on late night of 31.12.2018.


The representative of the Company reiterated the facts given in the SCN and informed that the

policy no. 301700453 was completed on 15.12.2007 with DOC as 04.11.2007. The same DOC is

mentioned in Policy Bond. The policy holder had paid the premiums for 11 years with the same

DOC as 04.11.2007. The life Assured died on 01.01.2019 ie after the days of grace of 15 days

from the first unpaid premium due 04.11.2018. As per terms and conditions of the plan, nothing is

payable under this policy. The Company has also stated that proposal was signed on 06.12.2007

with date backing as 04.11.2007, the policy holder never complained in past 11 years since 2007

that, the DOC is not correct. We are surprised that after the demise of the policy holder, the

complainant though his son complained that the DOC is incorrect.

18) The following documents were placed for perusal:-



19) Result of personal hearing with both parties (Observations & Conclusion)

I have examined the various documents available in the file including the copy of the complaint,

Annexure-VI and the contents of the SCN filed by the Insurance Company. It is evident from the

record that the date of commencement of policy mentioned on the policy bond is 04.11.2007. The

deceased Life Assured had paid the annual premiums under the policy for 11 years without any

objection. Unfortunately policy holder died on 01.01.2019 when the policy was lying in lapsed

condition with premium due for payment on 04.11.2018. Had the date of commencement of the

policy been 28.11.2007 as mentioned in the proposal form submitted by the complainant, the

status of the policy still remains lapsed as the life assumed died on 01.01.2019 after the grace

period of 15 days from the date of first unpaid premium ( 28.11.2018) as per the terms and

conditions of the policy. Here, even if we may consider the date of commencement of policy as

15.12.2007 as claimed by the complainant being the date of issue of the first premium receipt of

the subject policy, the days of grace are up to 30.12.2018 where as the Life Assured expired on

01.01.2019. Keeping in view the facts mentioned above, it is clear that the claim has been legally

and validly repudiated by the Insurance Company.

Dated at Chandigarh on 24th day of February, 2020

Dr. D K Verma

INSURANCE OMBUDSMAN

PROCEEDINGS OF THE INSURANCE OMBUDSMAN, DELHI

(Under Rule 13 of the Insurance Ombudsman Rules, 2017)

Ombudsman: Shri Sudhir Krishna

Case of Anjali Verma versus HDFC Life Insurance Company Ltd.

Case No. 498/19

Complaint Ref. No.: DEL-L-019-1920-0750

1. Name & Address of the Complainant Smt. Anjali Verma

J-174 A, Upper Ground, Khirki Extn.

Malviya Nagar, Delhi-110017

Mobile No.: 9971944306

2. Policy No:

Type of Policy

Policy Term/Premium paying term

19742847

Conventional

10/10 years



Sanjay Verma

Sanjay Verma

4. Name of the insurer HDFC Life Insurance Company Ltd.





9. Amount of Claim Rs. 17,00,000


11. Amount of relief sought Rs. 17,00,000


Company during the course of hearing, there is no need for any interference and the

complaint is dismissed.


12. Complaint registered under Rule 13 (1) (d) of the Insurance Ombudsman Rules 2017

13. Date of hearing/place 11.02.2020, Delhi


a) For the Complainant In person

b) For the Insurer Shri Kunal Aurora, Dy. Manager (Legal)

15. Complaint how disposed Award


17) Brief Facts of the Case: Smt. Anjali Verma (hereinafter referred to as the Complainant) has

filed the complaint against the HDFC Life Insurance Company Ltd. (hereinafter referred to

as the Insurer or the Insurance Company) for wrong repudiation of death claim on her

deceased husband under policy no. 19742847.


a) Complainant’s Argument:

The Complainant has alleged that her deceased husband Sanjay Verma had taken a policy

on 31.10.2017. At the time of taking policy, he was physically fit. Subsequently he was

diagnosed with metastatic carcinoma pancreas and died on 23.03.2019. The death claim

was repudiated on the grounds of suppression of material facts and the same was

communicated vide repudiation letter dated 02.05.2019. The Death Claim Sum Assured was

not paid, though the Fund Value of the Policy amounting to Rs. 3.50 Lakh approximately

was paid to the Complainant. She represented her case before the Claim Review Committee

of the Insurer. However the decision of repudiation was upheld by the Committee and was

communicated vide letter dated 07.08.2019.

b) Insurer’s Argument:

The Insurance Company has submitted that the claim was repudiated on the basis of

Medical Records found during investigation of the claim, which had revealed that the

Deceased Life Assured was a known case of CA Pancreas and had already undergone

chemotherapy for the same. The same was mentioned in the Death Claim Form submitted

by the claimant also.

19) Reason for Registration of Complaint:

Same as 18 (a) above.

20) The following Documents were placed for perusal:

a) Policy Documents

b) Correspondences between the Complainant and the Insurance Company

c) SCN by the Insurance Company 21. Result of hearing with the parties (Observation and Conclusion):

Case called. Parties are present and reiterate their respective arguments as noted in Para 18

above.

Insurer has relied on the medical prescription of the deceased life assured (DLA) from RHT

Multi-speciality Clinic dated 09.3.2017, which has noted that the DLA was having

chemotherapy for CA Pancreas. The DLA did not disclose this fact while applying for this

policy in October 2017.

Complainant denies this medical prescription and states that the DLA had no such illness in

2017.

It is difficult to overlook the medical prescription from RHT Multi-speciality Clinic.

Accordingly, the Insurer was justified in holding that the DLA had not disclosed the

material fact of his past ailment of cancer of pancreas while applying for this policy in

October 2017 and his death on 23.03.2019 was within three years of the issue of the policy.

Accordingly, repudiation of the death claim by the Insurer was justified as per Clause 6 of

Annexure III of the Policy.

Award

The complaint is rejected.

(Sudhir Krishna)

Insurance Ombudsman,

Delhi

February 2020

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF RAJASTHAN

UNDER THE INSURANCE OMBUDSMAN RULES, 2017

OMBUDSMAN – MS. SANDHYA BALIGA

CASE OF MUKESH SINGH V/S L I C OF INDIA

COMPLAINT REF: NO. JPR- JPR – L – 029-1920-0285

AWARD NO: IO/JPR/A/LI/ /2019-2020


Complainant

Sh. Mukesh Singh

Vill. Kheda Dand, PO- Kishan pura

Via- Kabra, The.- Beawar, Dt. Ajmer

2. Policy No:

Type of Policy

SA

DOC / Term

186413436

Life

50000/-

27.07.2009 / 20 years



Smt. Kanwari Devi

Smt. Kanwari Devi

4. Name of the insurer LIC OF INDIA ( DO- Ajmer)


6. Reason for repudiation Suppression of material facts




10. Date of Partial Settlement 20.03.2019 Rs. 26600/-



Rule no: of IOB rules

13 (1) (b)

13. Date of hearing/place 07.01.2020 / Jaipur


For the Complainant Absent on 07.01.2020, 28.01.2020 and

13.02.2020

For the insurer Sh. Anil Kumar Kasliwal

15 Complaint how disposed Dismiss


17) Brief Facts of the Case:- Sh. Mukesh Singh ( herein after referred as complainant) had filed

a complaint against LIC of India (herein after referred to as respondent Insurance Company) alleging non

settlement of Death Claim under policy no. 186413436 on the life of his mother Smt. Kanwari Devi


Complainants’ argument: The complainant submitted that subject policy was taken by his

mother late Smt. Kanwari Devi on 27.07.2009 under Money Back Plan from the respondent

Insurance Company. The insured died on 04.11.2018 during treatment. Insurance Company paid

only the installment amount instead of full claim amount. The complainant approached the GRO

for the settlement of death claim benefit, but did not get any relief. Being aggrieved the

complainant approached this forum for redressal of his complaint.

Insurers’ argument:- :- The respondent Insurance Company in its SCN dated 30.11.2019

submitted that in the subject policy was issued on 27.07.2009. Policy was revived on 03.11.2018

that was just one day before the death of the insured. During claim investigation the facts were

revealed that the insured had been admitted in the Govt. JLN Hospital, Ajmer from 09.10.2018

to 13.10.2018. As per BHT of the hospital the DLA was suffering from HIV / TB. These

material facts were not disclosed while reviving the policy. Had these facts been disclosed at the

time of revival, the policy would have not been revived. As such it was decided to cancel the

revival at the Divisional Office Level. Since policy had acquired paid up value before revival,

paid up value Rs. 26600/- was paid to the claimant. The complainant made an appeal to the

GRO for reconsideration of the claim, which was considered favorably and the claim was

“admitted by the Insurance Company on ex- gratia basis for Rs. 50000/- including amount

already paid”. Accordingly balance amount of the claim i.e. Rs. 23400/- was paid to the

claimant on 28.11.2019.

19) Reason for Registration of Complaint: Repudiation of Death Claim.


a) Complaint letter

b) Policy copy

c) Form VI A duly signed by the complainant.

d) SCN and form VIIA duly signed by the Insurance Company

21) Result of hearing with both parties (Observations and Conclusion): Hearing in the case

was scheduled on 07.01.2020, 28.01.2020 and 13.02.2020. The complainant was absent. Over

telephone he requested for rescheduling the hearing to 13.02.2020. Accordingly the hearing in

the case was rescheduled to 13.02.2020, but the complainant was absent. I heard the Insurance

Company.

On perusal of documents exhibited, I find that sufficient opportunity was provided to the

complainant, but he was absent and no further communication was received from him.

“Accordingly, the complaint is hereby dismissed in default”

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


a. According to Rule 17(5) of Insurance Ombudsman Rules, 2017, a copy of the award shall be sent to

the complainant and the insurer named in the complaint.

Place: Jaipur SANDHYA BALIGA

Dated: 13.02.2020 (INSURANCE OMBUDSMAN)

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF WEST BENGAL, SIKKIM, A&N ISLANDS

(UNDER RULE NO: 16(1)/17 of THE INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN – P. K. RATH

CASE PURNIMA DEY V/S BHARTI AXA LIFE INS. COMPANY LTD

COMPLAINT REF: NO: 1) KOL-L-008-1819-0120 AWARD NO: 1) IO/KOL/A/LI/ 0611 /2019-2020

1. Name & Address of the Complainant

PURNIMA DEY C/o, Ratan Dey, FW-9/A, Rabindrasarani, Jangra Dakshin Math,

Baguihati, Kolkata – 700059. W.B. 2. Policy No:

Policy Type/Duration/Period 506185182

DETAILS ARE IN THE TABLE 3. Name of the Insured/LA

Name of the proposer RATAN DEY

SELF

4. Name of the insurer BHARTI AXA Life Ins. Co. Ltd.

5. Date of Repudiation Not Applicable 6. Reason for repudiation Not Applicable 7. Date of receipt of the Complaint 24.05.2018 8. Nature of complaint Dispute with regard to any Partial or Total Repudation of claims

AWARD

Taking into consideration the facts and circumstances of the case , the complaint is here by

dismissed in default.

by the insurer – 13-1(b) 9. Amount of Claim Rs. 142809 + Bonus

10. Date of Partial Settlement Not applicable

11. Amount of relief sought Rs. 142809/- + Bonus 12. Complaint registered under

Insurance Ombudsman Rules’ 2017 13 (1) (b)

13. Date of hearing/place 28.01.2020, AT KOLKATA 14. Representation at the hearing

For the Complainant PURNIMA DEY

For the insurer BIRESWAR BHATTACHARJEE

15 Complaint how disposed BY CONDUCTING HEARING 16 Date of Award/Order 14.02.2020

17) Brief Facts of the Case: Pol No L.A. PLAN DOC Premium

(yly) Term /PPT

1ST Comp to Ins Co

5016185182 RATAN DEY Conventional 11.09.2017 6600/- 12/12 19.02.2018

The complainant has alleged the following:- i) The complainant is the nominee and wife of the deceased life assured under the policy and

submitted that they had no intention to take a policy but with the package of allurements of getting huge money, mediclaim benefits, loan, home loan etc. compelled to take the above policy but till date have not received any policy document or related documents. She also submitted that before the death of her husband when he was admitted in the hospital, tried to get back the refund of premium under the policy but the insurance company did not entertain their request and instead they advised to keep the policy in force and not to cancel the policy because in case of death of the life assured they will get the Death Benefit under the policy which will be much beneficial.

ii) In the mean time her husband expired on 13.12.2018 and accordingly she submitted the papers for payment of death claim under the policy on 19.02.2018 but the insurance company repudiated the death claim on the ground of suppression of material fact at the time of taking the policy and nothing is payable under the policy.

Being aggrieved, the complainant has now approached this forum for redress of his grievance.

18) Cause of Complaint: Due to mis-selling of policy.

Complainant’s argument: In point No. 17 it is mentioned categorically.

Insurers’ argument: As per SCN received from the insurer, at the outset they have denied all the

allegations made by the complainant and termed as false, incorrect and frivolous. They also raised

the following points :

a) Policy has been issued only after receipt of duly filled up application form and relevant declaration regarding full understanding of policy terms and conditions along with valid KYC documents submitted by the complainant cum policyholder.

b) The policy bond along with copy of proposal form and signed benefit illustrations had been despatched and delivered.

c) They finally repudiated the claim on the ground of suppression of material fact in the Proposal Form and on the following grounds : i) That he was suffering from chronic Lever Disease, Kidney Disease, Prostate

Problem, etc., long before the date of proposal but did not disclose in the proposal

paper. Necessary treatment particulars have been produced in support

of their claim for ready reference.

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

regarding any partial or total repudiation of claim under rule 13 (1)(b)


i) Complaint letter ii) P – form iii) Proposal papers iv) SCN

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

The complainant was the wife and nominee under the above noted policy, repeated the allegations

as made in her complaint letter and also submitted that the policy was issued on the life of her

husband by calling both of them in a office of Bharti Axa Life Ins. At Kestopur by the

Agent/Intermediary of Bharti Axa Life Insurance Co. Though they have no intention to take the policy

and was not in a position to pay the required amount still somehow managed by taking personal loan

from relative and paid the amount and got the receipt. She also submitted that no Policy Terms and

Conditions discussed with them and also not questioned anything about them or about her husband,

her husband only signed on some papers as guided by the Agents/Intermediaris. In support she

produced a Certificate of 3rd Prize Winner of the Competition. She also submitted that at the time of

taking the policy her husband was of quite good health, hard working jolly person and had not

suffering from any major disease except some mild acidity and cough and cold. She also submitted

that she is very unfortunate lady and living with her two daughters and wants to get the Death Claim

Benefit under the policy at the earliest.

The representative of the Insurance Co. raised objection against the complainant but probably

realizing role of the agents and submission of documentary proof by the complainant and also as he

could not produce any PIVC proof/record in their support, he prevented himself to raise any further

arguments in this matter. However, he expressed his best cooperation with a view to amicable

settlement of the case.

AWARD

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

the parties, I am of the opinion that there was no deliberate suppression of facts either by the

policyholder, Late Ratan Dey, or by the Nominee under the policy, Smt. Purnima Dey. It is evident

from the USG Report dt. 09.04.2016 that Late Ratan Dey was not suffering from Chronic Liver

Disease as on 09.04.2016, nor could the Investigator, deputed by the Insurer, establish any

suppression of material facts. So The Insurer, Bharti Axa Life Insurance Co. Ltd., is directed to Pay

Full Death Claim Benefit under the Policy together with accumulated Bonus as per Terms and

Conditions of the policy, under intimation to this office.

Hence, the complaint is treated as disposed of.

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


As per Rule 17(6) of the Insurance Ombudsman Rules 2017, the Insurer shall comply

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

compliance of the same to the Ombudsman.

Sd/

Dated at KOLKATA on 14th day of Feb.,2020 P. K. RATH

INSURANCE OMBUDSMAN

FOR THE STATE OF WEST BENGAL,

SIKKIM and A&N ISLANDS

PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN , STATES OF WEST BENGAL, SIKKIM AND UT OF A & N ISLANDS (UNDER RULE NO: 16(1)/17 of INSURANCE OMUDSMAN RULES, 2017)

OMBUDSMAN – SHRI PRADIP KUMAR RATH CASE OF ---MRS. RANI KHATTRI

V/S BIRLA SUNLIFE INSURANCE CO. LTD.

COMPLAINT REF NO: KOL-L-009-1819-0537

AWARD NO: IO / KOL/A/LI/ 0512 /2019-2020

1. Name & Address of the Complainant MRS. RANI KHATTRI D-11/3, PURBASHA HOUSING ESTATE 160, MANICKTALA MAIN ROAD, KOL-700054 E-mail ID:

MOB NO : 9830297956 2. Policy Nos.

Type of Policy Duration of policy/Policy period

005254286 BIRLA SUNLIFE BACHAT ENDOWMENT PLAN

2 YEAR (PREM. PAID 1 YEAR)

3.

Name of the Insured Name of the Policy Holder

SHRI ANIL KUMAR KHATTRI Self

4. Name & address of the insurer BIRLA SUNLIFE INSURANCE CO. LTD.

5. Date of Repudiation 30/12/2013 6. Date of lodgement of complaint to

Insurer 24/09/2015


8. Nature of complaint REPUDIATION OF DEATH CLAIM 9. Amount of Claim Rs.261600/

10. Date of Partial Settlement ---- 11. Amount of relief sought RS.1046400/ as per P form.

12. Complaint registered under IOR 2017 13(1)(b)

13. Date of hearing/place 07/01/2020 AT KOLKATA 14. Representation at the hearing For the Complainant NISHA MEHROTRA For the insurer MR. RANIT MANNA 15 Complaint how disposed BY CONDUCTING HEARING AT KOLKATA

16 Date of Award/Order 10/02/2020

17 Brief Facts of the Case

POLICY NO. D.O.C. NAME T/PPT PREMIUM INCLUDING TAX

POL. BOND RECEIVED

5254286

09/12/2011

Mr. Anil Kumar Khattri --- Rs51003/

RECEIVED

Complainant’s Argument: (a) The complainant Mrs. Rani Khattri, wife of the deceased & nominee of the above policy alleged

that the cheque of Rs.50000/ handed over to the intermediary by Mr. Anil Kumar Khattri (deceased) for paying the renewal premium of his own policy, fraudulently utilised the same to introduce a new policy on the life of Smt. Rani Khattri without intimating anything to Mr. Anil Kumar Khattri. As a result, Mr Khattri was under impression that the renewal prem. of his policy was already paid against the due 09/12/2012. Unfortunately Mr. Khattri expired on 05/12/2013.

(b) When she submitted the death claim on the policy – 5254286, the Insurer denied to settle the claim in view of the policy in question stands lapsed since 09/12/2012.

(c) Mrs. Khattri directly charged the Advisors for the lapsation of the policy as the advisors deliberately made the policy lapsed for his personal vested interest in the new policy.

(d) She also alleged that in the new proposal, no photo of herself was attached, instead the photo of her husband was attached. She also informed that her husband was not at all conversant

with Insurance rules and as such he relied absolutely on the advisors. Moreover no renewal prem. due notice or lapse notice was served to them by the Insurer.

Insurer’s argument:

As per SCN submitted by the Insurer, we find the following arguments –

a) That the Life Assures has paid only the initial premium and did not pay any further premiums to continue the policy. Hence the life assured himself waived the right to remain covered.

b) That the said policy lapsed on 09/12/2012 when life assured was alive and the Insurer communicated to the life assured vide letter dated 18/01/2013. Thus the life assured wilfully neglected to revive the policy within the grace period and the policy gradually lapsed.

c) That the complainant (nominee of the policy in question) lodged the first complaint about repudiation of claim on 24/09/2015, almost after 2 years from the date of repudiation.

d) That on the basis of above, the Insurer demanded that the complaint is baseless, frivolous and devoid of merit and prayed for dismissal of the complaint.

19) Reason for Registration of Complaint: Scope of The IOR, 2017 under rule

13(1)(b).

20) The following documents were placed for perusal by Complainant.

a) Annexure – VI-A, b) complaint letter c) complaint letter lodged to Insurer & their Response,

d) Copy of proposals e) Copy of Policy documents.

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

Complainant’s Submission:

The representative of the complainant Smt. Nisha Mehrotra, daughter of Smt. Rani Khattri appeared in

the hearing as her mother expired on 06/02/2019. She repeated all the points as mentioned in the

complaint letter, lodged to us on 06//03/2018. She added that her father was not in a position to respond

to any query since December 2012 as he was just under treatment of cancer at that time. She also

added that so far she knew, no notice of premium due or lapsed notice was received from the Insurer.

She appealed for settlement of death claim on the basis of payment made for renewal premium but the

amount was misutilised by opening a new policy instead of paying the renewal premium of the policy in

question by the Intermediary for his own vested interest.

Insurer’s Submission:

The representative of the Insurer also repeated all the points as mentioned in their SCN. He also added

that renewal premium notice or lapsed notice was sent to the Insured in due time but he knowingly did

not pay the renewal premium. So the onus of lapsation lies with the Insured. In the question of

verification call, the representative replied that no verification call used to be done by the Insurer at that

time. However he could not reply our question – “Why the photo of proposer was attached in stead of life

assured in the questionable proposal”. He demanded dismissal of the complainant.

AWARD Taking into account the fact and circumstances of the case and after going through the documents on record and the submissions made by both the parties during the course of hearing, it is observed that a new policy (policy no. – 5848763) was introduced on 30/11/2012 with yearly premium Rs.50006.80/ on the life of Mrs. Rani Khattri, wife of Shri Anil Kumar Khattri who was the proposer of the policy. But we find a lot of discrepancies in the new proposal as under – a) In the said proposal, the photo of the proposer was attached instead of the photo of the the life assured. b) That the policy was introduced without taking any income proof of the proposer (life assured was house wife) although total premium including the premium of the earlier policy crosses one lakh. c) That a long term regular paying policy (term 18 years) was issued to a proposer whose age at that time was 61 years. That is, the proposer was supposed to pay premium till he is 79 years. In general, no senior citizen agrees to go for such a long-term contract. d) That the new policy was introduced without any Nominee. d) That, no benefit illustration form found with the proposal. However, these discrepancies in the new policy are not sufficient to prove that the amount was meant for renewal premium of the policy number 5254286. Hence the contention of the Insurer is sustained on repudiation of Death Claim as the policy being in lapsed condition. But the Company is directed to cancel the new Policy No. 5848763 and refund the premium Rs.50006.80 along with Interest @ 2% above present Bank Interest for the period from 30/11/2012 to date of award in favor of legal heir of Mr. Anil Kumar Khattri (proposer of the policy 5848763), under intimation to this forum. Hence, the complaint is disposed of. 22) The attention of the Complainant and the Insurer is hereby invited to the following

provisions of Redressal of the Insurance Ombudsman Rules, 2017. As per Rule 17(6) of the

said rules the Insurer shall comply with the Award within 30 days of the receipt of the award

and shall intimate the compliance to the Ombudsman.

Dated at Kolkata, the 10th day of February 2020.

S/d P.K. RATH INSURANCE OMBUDSMAN FOR THE STATE OF WEST BENGAL,

SIKKIM AND UT OF ANDAMAN & NICOBER ISLANDS

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATES OF WEST BENGAL, SIKKIM

AND UT OF ANDAMAN & NICOBAR ISLANDS (UNDER RULE NO: 16(1)/17 of


OMBUDSMAN: – SHRI P.K.RATH

CASE OF MR. PRATIM CHATTERJEE V/S

HDFC STANDARD LIFE INSURANCE CO. LTD. (MUMBAI)

COMPLAINT REF: NO: KOL-L-019-1819-0933

AWARD NO: IO/KOL/A/LI/ 0633 /2019-2020


Mr.Pratim Chatterjee S/o. Late Partha Chatterjee, 32,M G Road,

Kolkata, West Bengal- 700 009 Mob. 7003179118

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

Pol. No:18045343 Details of the policy are given in the Table below.

--do--

3. Name of the insured Name of the policyholder

Mr. Partha Chaterjee --do--

4. Name of the insurer HDFC STANDARD LIFE INSURANCE CO. LTD. (MUMBAI)

5. Date of Repudiation 20.09.2018 6. Reason for repudiation False disclosure of Occupation Income details 7. Date of receipt of the Complaint 18.01.2019 at the office of Ins. Ombudsman 8. Nature of complaint Repudiation of Claims 9. Amount of Claim Rs.700000/-

10. Date of Partial Settlement N.A. 11. Amount of relief sought Not defined

12. Complaint registered under The Insurance Ombudsman Rules, 2017

Partial Repudiation of Claims by Insurer Rule 13(1)(a)

13. Date of hearing/place 11.02.2020 AT KOLKATA 14. Representation at the hearing

For the Complainant Mr. Pratim Chatterjee

For the insurer Mr. Sumit Saha & Ms. Koyel Ghosh

15. Complaint how disposed BY CONDUCTING HEARING 16. Date of Award/Order 28.02.2020

17) Brief Facts of the Case:-- Details of the policy issued:

Pol. No. & DOC 18045343 & 21.12.2015

Plan Name HDFC Life ProGrowth Plan

Name of Policyholder/Life assured Mr. Partha Chatterjee (Both)

PT/PPT Yrs. 10/10

Inst. Prem. & Mode Rs.100000/- & Yearly

Sum Assured Rs.700000/-

Date of Complaint to Insurance Company 08.08.2018

First unpaid premium Total Premium Paid Rs. 300000/-

Duration= (DOC – Date of Complaint) Death claim

Pol. Bond Delivery

Name of Broker/ Agent. HDFC Bank Code No.00612149

The complainant had alleged against the Insurance Co. on the following points:

01. That the Complainant being a nominee of the policy lodged his complaint to this forum on

18.01.2019 in regard to partial repudiation of claims.

02. That his father, Mr. Partha Chatterjee purchased a policy of HDFC Life ProGrowth Plan with age

at entry 58,

03. DOC 21.12.2015, PT/PPT 10/10, Mode yearly and Sum Assured Rs.700000/- and premium paid

up to his death. He died on 18.01.2018.

04. That the policy was resulted into claim by death of the life assured on 18.01.2018.

05. That the death claim was submitted to the insurer on 08.08.2018 by the nominee along with all

the necessary documents. The death occurred on 18.01.2018 i.e. after 25 months of policy

issued.

06. That after submission of death claim papers an investigation was conducted by Mr. Soumendra

Rai on behalf of the insurer on 25.08.2018. He had taken snaps of all the documents like as Pan

Card, Aadhaar card, Death certificate, Post Mortem and Police Inquest Repost. Mr. Rai raised

some suspicions in regard to death claim payments and asked Mr. Chatterjee to meet at his

hotel along with Bank details for providing undue benefits of claim.

07. That it was assumed that as the complainant denied the offers given by the investigator so the

claim was admitted by the insurer for refund of premium.

08. That after that an amount of Rs.339283.25/- was paid to the complainant by NEFT on

17.09.2018 instead of Sum Assured of Rs.700000/-.

As such, being dissatisfied with the decision of the insurer for partial repudiation of claim, the

complainant has now approached this forum for redressal of his grievance.

18) Cause of Complaint: Partial Repudiation of Claims by the Insurer.

Complainant’s argument: Already briefed under point 17

Insurer’s argument: SCN has not been received from Insurance Company. So, the findings

of the Insurance Company are not available with us. However, Death claim letter dated

20.09.2018 issued by the insurer to the complainant wherein they stated that the proposal

was accepted on the basis of information provided in the proposal form and the policy was

issued on 21.12.2015 with Sum Assured Rs.700000/-.They also stated that on investigation

it was established that his occupation and income details disclosed in the proposal form are

found to be false. It has been established that the life assured was involved in illegal activity

of child trafficking and no documentary proof of legal income. In view of the above they

have declined the application. They paid an amount of Rs.339283.25/- towards the refund

of premium payable under the said policy.

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

13(1) (b), Partial Repudiation of Claims by the Insurer.


a) Complaint letter to the Ombudsman & to the Ins. Co.

b) Annexure VIA/ P form.

c) Copies of proposal form, FPR and policy schedule.

d) Copies of correspondences.

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

Both the parties participated in the hearing.

Complainant’s submission:

The complainant stated that he is nominee of the policy and works in Primary Health Centre.

He submitted that his father was detained at Dum Dum Central Correction Home I/C/W

Baduria PS case no.815/16 dt. 22/11/16 u/s 369/370(5)/315/120B/34 IPC. The said UTP was

admitted at SSKM Hospital on 17.01.2018 and breathed his last on 18.01.2018.

His father had an Ad Agency. During his detention at Centre Correction Home, the renewal

premium was deposited through ECS.

In respect of his source of income, the complainant expressed his willingness to submit to the

insurer within 15 days.

Insurer’s submission:

The representatives of the insurer repeated what they have been already stated in their SCN.

They also stressed upon his source of income as well as his business dealing with.

AWARD:-

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

parties present during the course of hearing and after going through the relevant documents on

record, it is observed that the complainant could not submit any documentary evidence of the

deceased life assureds’ business dealing with proof of income proof within 15 days of the hearing.

Hence, no relief is provided to the complainant in respect of his complaint lodged to this Office

against Policy No. 18045343.

Accordingly, the complaint is treated as dismissed.


the Insurance Ombudsman Rules, 2017:

As per Rule 17(6) of the said rules the Insurer shall comply with the Award within 30 days of the receipt

of the award and shall intimate the compliance to the Ombudsman.

Dated at Kolkata, 28th February, 2020

S/d

Shri P.K.Rath

INSURANCE OMBUDSMAN

FOR THE STATES OF WEST BENGAL,

SIKKIM AND UT OF ANDAMAN & NICOBAR ISLAND

PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WEST BENGAL, SIKIM, A&N ISLANDS

(UNDER RULE NO: 16(1)/17 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN – MR.P.K.RATH

CASE OF MRS. SWAPNA GIRI

V/S

LIC of INDIA

COMPLAINT REF: NO: 1) KOL-L-029-1819-0380

AWARD NO: 1) IO/KOL/A/LI/ 0516 /2019-2020


Mrs. Swapna Giri

23/4, Gariahat Road, Golpark,

Kolkata, West Bengal

PIN : 700 029, Mob No.9903997238

2. Policy No: 579470922 & 579470923

Policy Type/Duration/Period DETAILS ARE IN THE TABLE

3. Name of the Insured/LA

Name of the proposer

Mr. Gopal Chandra Giri (Deceased Life Assured - DLA)

----------------------------Do-------------------------

4. Name of the insurer LIC of INDIA (KMDO-II)

5. Date of Repudiation Not Applicable

6. Reason for repudiation Not Applicable


8. Nature of complaint Dispute regarding deduction in claim amount on death of annuitant



11. Amount of relief sought @Rs.44,375/- for two policies = Rs 88,750/- plus interest till date


Insurance Ombudsman Rules’ 2017 13 (1) ( e )

13. Date of hearing/place 10-01-2020 & 06-02-2020 AT KOLKATA


For the Complainant Mr. Tapan Kumar Giri (Husband of Complainant)

For the insurer Ms.Dipu Bala Sarkar, Manager (CRM) & Mr.Ashesh Ghosh, A.O., LICI, KMDO-II

15 Complaint how disposed BY CONDUCTING HEARING

16 Date of Award/Order 10-02-2020


The complainant has alleged the following:-

iii) That the Deceased Life Assured (DLA) purchased two immediate annuity (Jeevan Akshay VI) policies from LIC of India on 28-02-2011 with purchase price of Rs.7.50 lakh each.

iv) That the annuitant expired on 01-12-2013 and the nominee of the policies, the present Complainant, applied for return of purchase price from the insurer in July’2014 intimating death of the annuitant.

v) That the insurer released the purchase price of the two policies to the Complainant after deducting a total of Rs.88,750/- i.e. Rs.44,375/- each in two policies.

vi) That it was understood by the Complainant that the insurer released the full yearly annuity due on 01-03-2014 due to late submission of death intimation of the annuitant. But then they could deduct the proportionate annuity for 3 months (01-12-2013 to 28-02-2014) only as the annuitant was alive for 9 months of the year from 01-03-2013 to 30-11-2013. Moreover, the insurer held the money up

to the settlement of claim, as such no money should have been deducted at all from the purchase price.

vii) That the Complainant wrote several times to the insurer for proper clarification of the deducted amount from the purchase price but did not receive any response from the insurer.

Being dissatisfied with the indifference of the insurer in providing the reason behind the deduction of

the aforementioned amount from the purchase price, the complainant has now approached this

forum for redressal of his grievance.

Details of the policy issued:

Policy No. 579470922 579470923

Name of Annuitant Mr.Gopal Chandra Giri Mr. Gopal Chandra Giri

Name of the

Nominee/relationship

Ms. Swapna Giri (Daughter

in law)

Ms. Swapna Giri (Daughter in

law)

Plan/Term/PPT Jeevan Akshay VI 189

/ 00 / 01

Jeevan Akshay VI 189 /

00 / 01

Date of Commencement 28-02-2011 28-02-2011

Date of Vesting 28-02-2011 28-02-2011

NCO/Purchase Price Rs. 7,50,000/- Rs. 7,50,000/-

Date of Death 01-12-2013 01-12-2013

Death intimation July 2014 July 2014

Annuity due on Amount of annuity paid Amount of annuity paid

01-03-2012 Rs.(162* + 58,950) Rs.(162* + 58,950)

01-03-2013 Rs. 58,950 Rs. 58,950

01-03-2014 Rs. 58,950** Rs. 58,950**

Return of Purchase Price Rs. 7,50,000 Rs. 7,50,000

Less annuity paid on 01-03-

2014 after death Rs. 58,950 Rs.58,950

Less broken period annuity

paid on 01-03-2012 Rs. 162 Rs.162

Amount paid to nominee Rs. 6,90,888 Rs. 6,90,888

* Annuity for the Broken Period 28-02-2011 to 28-02-2011

** Annuity due on 01-03-2014 i.e. paid after death of annuitant on 01-12-2013

18) Cause of Complaint: Due to repudiation / rejection of death claim.


Insurers’ argument: As per SCN received on 10-12-2018 the submission of the Insurance Company in this case is as follows :-

a) That the annuitant expired on 01-12-2013 and hence no annuity due after the date of death is payable. The death was intimated by the Complainant after the release of annuity due on 01-03-2014 which was not payable.

b) That the annuity due on 01-03-2014 wrongly released due to late receipt of death intimation was deducted from the purchase price along with the broken period annuity of one day as per terms and condition of the policy.

c) Total Purchase price for each policy : Rs. 7,50,000 Less: annuity released after death on 01-03-2014 : Rs. 58,950

Less: broken period annuity of one day : Rs. 162

Amount paid to the nominee for each policy : Rs. 6,90,888

d) That the amount of Rs.6,90,888 paid corectly to the nominee for each of the two policies under complaint as per terms and condition of Jeevan Akshay VI Plan printed on front page of policy document.

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

payment of death claim on death of annuitant – 13 (1) (e)


ii) Complaint letter ii) P – form iii) Proposal papers iv) SCN


The representative of the Insurance Company was present in the hearing on 10-01-2020 but the

Complainant did not turn up on that day. However, both the parties were present in the re-hearing

conducted on 06-02-2020. The Complainant was represented by her husband, Mr.Tapan Kumar Giri as

authorized by the Complainant with the permission of Hon’ble Ombudsman.

The representative of the Complainant admitted that one yearly instalment of annuity due after the

date of death of annuitant had been received by them because of late intimation of death to the

insurer from their part. He pointed out that proportionate amount of this annuity instalment for the

period of 9 months for which the annuitant was alive has not been paid by the insurer.

The representative of the Insurance Company clarified that no annuity instalment is payable after the

death of the annuitant as per terms and condition of the policy. Hence the full yearly annuity

instalment released after the death of annuitant by the insurer due to late receipt of death intimation

was correctly deducted during return of purchase price to the nominee for these two policies under

complaint as per rules.

AWARD


parties during the course of hearing, it is observed that the annuitant expired on 01-12-2013 but the

yearly annuity due on 01-03-2014 had been released by the insurer due to late intimation of death

by the Complainant. As per terms and condition of the policy mentioned in the policy document

“where the Annuity ceases on the death of the Annuitant, no part of the said Annuity shall be

payable or paid for such time as may elapse between the date of payment immediately preceding

the death of Annuitant and the day of his/her death”.. Thus in this case the annuity paid after the

date of death of the annuitant was not payable and as such the amount paid by the insurer to the

nominee as final settlement of these two policies are correct as per terms & condition of the plan of

the insurer.

Hence, the complaint is treated as disposed of without providing any relief to the Complainant.



As per Rule 17(6) of the Insurance Ombudsman Rules 2017, the Insurer shall comply with the Award

within 30 days of the receipt of the award and shall intimate the compliance of the same to the

Ombudsman.

Sd/-

Dated at KOLKATA on 10th day of February 2020. P.K.Rath

INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WEST BENGAL, SIKIM, A&N ISLANDS (UNDER RULE NO: 16(1)/17 of THE INSURANCE OMBUDSMAN RULES, 2017)


CASE OF MS. RUPALI BASAK

V/S

LIC of INDIA




Ms Rupali Basak C/o.Late Lakshman Basak, Lakshmiganj Bazar, Nimtala, PO-Chandannagar, Hooghly, West Bengal – 712 136. Mobile No. 9163995960

2. Policy No: Policy Type/Duration/Period

487715082 DETAILS ARE IN THE TABLE

3. Name of the Insured/LA Name of the proposer

Mr. Lakshman Basak (Deceased Life Assured - DLA) ---------------------------Do--------------------------

4. Name of the insurer LIC of INDIA (Howrah Division) 5. Date of Repudiation 22-11-2017

6. Reason for repudiation Suppression of material facts regarding previous proposals

7. Date of receipt of the Complaint 04-09-2018 8. Nature of complaint Dispute with regard to repudiation of claim 9. Amount of Claim Rs.5,00,000


11. Amount of relief sought Rs.2,08,020 with interest as per P-form

12. Complaint registered under Insurance Ombudsman Rules’ 2017

13 (1) ( b )

13. Date of hearing/place 10-01-2020 AT KOLKATA 14. Representation at the hearing

For the Complainant Ms. Rupali Basak

For the insurer Mr. Subho Dasgupta, A.O. (Claims),LICI, HDO.

15 Complaint how disposed BY CONDUCTING HEARING 16 Date of Award/Order 05-02-2020

17) Brief Facts of the Case: The complainant has alleged the following:-

viii) That the Deceased Life Assured (DLA), Lakshman Basak, purchased the abovementioned Jeevan Saral policy from LIC of India having Death Sum Assured Rs.5 lakh on 28-12-2013 with annual premium of Rs.6,125/-.

ix) That the DLA, a Toto driver, suddenly fell from his Toto on 11-12-2014 and was taken to S.D. Hospital Chandannagar where he was declared brought dead. The cause of death as per the Police Report dated 12-03-2015 is “due to the effect of internal hemorrhage” based on the Post Mortem Report.

x) That the nominee of the policy who is the wife of DLA & the present Complainant as well, lodged her claim to the LIC of India on 27-04-2015. The Insurance Company called for requirements on treatment particulars of DLA of his alleged heart disease prior to taking the policy after more than one year of receiving the death intimation.

xi) That the Complainant duly replied to the insurer that DLA died of cerebral stroke and never had any heart problem.

xii) That the Insurance Company finally rejected the claim vide their letter dated 22-11-2017 on the ground of false information provided by the DLA in the proposal form while taking the policy under complaint. That he suppressed the material fact that out of his four proposals prior to this current policy to this same insurer, three were accepted with Class VII extra.

xiii) That the death claim under another Policy bearing no.496075095 of the DLA was settled by the same insurer in spite of the false answers provided by him if any, and allegation sought to be made was clearly an afterthought to reject this claim with ulterior purpose.

xiv) That the Complainant made his representation against the decision of repudiation of claim to the Zonal authority of the insurer on 25-04-2018 but the decision of repudiation was upheld by Zonal Office Claim Disputes Redressal Committee.

Being dissatisfied with the insurer’s decision of repudiation of claim and rejection of his appeals by

the higher authority of the insurer, the complainant has now approached this forum for redressal of

his grievance.


Policy No. 487715082

Name of Life Assured Mr. Lakshman Basak

Name of the Nominee/relationship Ms. Rupali Basak (Wife)

Plan/Term/PPT Jeevan Saral (165 / 12/ 12)

DOC 28-12-2013

Premium/Mode Rs. 6,125/- (Yearly)

Death Sum Assured Rs. 5,00,000/-

Maturity Sum Assured Rs. 2,08,020/-

FUP of policy 28-12-2014

Date of death 11-12-2014

Status of the policy as on date of death Inforce

Duration of policy 15 days less than 1 year

Date of repudiation / rejection of claim 22-11-2017 (DO)

10-08-2018 (ZO)

Date of 1st complaint to Ombudsman 04-09-2018



Insurers’ argument: The submission of the Insurance Company as per SCN received on 09-11-2018 is as follows:-

e) That the DLA had total five policies with the insurer including the policy under complaint and the details of the policies have been appended below:

f) That the DLA expired on 11-12-2014 due to Internal Hemorrhage and in the Proposal Form of this policy, the DLA mentioned this as the first proposal but he had four policies (Sl. No.1-4) prior to this as detailed in the above table.

g) That prior to proposing this policy, DLA submitted four proposals which were accepted by the respondent insurer with modified term of Class VII health extra which were not finally translated into policies as consent not given by the DLA regarding acceptance of modified term.

h) That the decision of repudiating the claim due to suppression of material facts on aforementioned ground was communicated to the nominee vide letter dated 22-11-2017.

i) That the Zonal Office Claim Disputes Redressal Committee (ZOCDRC) reviewed the claim and decided to uphold the repudiation action taken by Howrah Divisional Office which was intimated to the nominee of the policy vide letter dated 10-08-2018.

Sl. No. Policy No. DOC/DOR P/T/PPT S.A. Status

1 434871396 28-11-2002 14/6/6 23,000 Maturity paid

2 434871397 28-11-2002 14/6/6 23,000 Maturity paid

3 436246895 28-06-2005 164/10/10 5,00,000 Lapsed w/o GSV

4 496075095 12-10-2010 165/15/15 2,00,000 Death claim paid

5 487715082 28-12-2013 165/12/12 5,00,000 Repudiated

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

total repudiation of claim by insurer – 13 (1) (b)


iii) Complaint letter ii) P – form iii) Proposal papers iv) SCN


Both the parties attended the hearing on 10-01-2020 at the Office of the Insurance Ombudsman,

Kolkata.

The Complainant introduced herself as the nominee and widow of the deceased life assured of the

policy under complaint. She informed that her husband was a Toto driver and he had total five policies

with this insurer. Her husband received maturity benefits in his two policies before his death. She does

not comprehend how the same insurer can reject death claim against this policy when they have

already settled the same on the life of his deceased husband in another policy. She also mentioned that

medical examination of her husband was conducted by the appointed doctor of the insurer before

issuing the policy and so they cannot deny the claim on health ground.

The representative of the Insurance Company reiterated the facts already mentioned in their SCN. They

clarified further that the deceased Life Assured did not mention about his four existing policies in the

proposal form of the present policy. He also did not disclose the fact that four of his previous proposals

prior to this present policy were accepted by the same insurer with Class VII extra premium over

ordinary rate on the basis of extra mortality rating of his life due to substandard health condition which

were not resulted into policies as he did not give his consent to pay the extra premium. As a result the

insurer was misled in the aspect of assessing the risk while underwriting the proposal and the death

claim was repudiated accordingly.

During the course of hearing the Hon’ble Ombudsman instructed the representative of the Insurance

Company to furnish the following documents within 7 days from date of hearing:

(i) Copy of the present proposal form, (ii) Documentation of the decision of the insurer on acceptance

of the previous proposals with Class VII extra premium and (iii) Copy of the proposal for the policy in

which death claim has been settled.

The compliance of the Insurance Company on aforementioned particulars has been received by this

Office on 03-02-2020.

AWARD


parties during the course of hearing, it is observed that the Deceased Life Assured had a long history

of purchasing insurance policies since 2002. Thus he must be knowing the norms & implications of

filling in the proposal forms correctly. But it is evident that in the proposal form of this policy under

complaint he not only withheld information of his previous policies but also failed to disclose the fact

that his four proposals prior to this policy submitted by him to the same insurer were accepted at

modified terms with health extra which were not resulted into policies due to his non-approval. This

definitely had bearing on assessment of risk by the insurer while accepting the proposal. As such the

decision of Insurance Company to repudiate the claim seems to be justified.






Ombudsman.

Sd/-


INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE



CASE OF MRS. MANJU RANI BANERJEE V/S LIC of INDIA




Mrs. Manju Rani Banerjee W/o. Late Madhusudan Banerjee C/o. Indranil Bhattacharya, 8/4, Anandapuri Co-op., Durgapur, West Bengal PIN : 713 213, Mob.No.9474371427




Madhusudan Banerjee (Deceased Life Assured - DLA) ----------------------------Do-------------------------

4. Name of the insurer LIC of INDIA (Asansol Division)

5. Date of Repudiation Not Applicable 6. Reason for repudiation Not Applicable 7. Date of receipt of the Complaint 14-08-2018

8. Nature of complaint Dispute regarding deduction in claim amount on death of annuitant



11. Amount of relief sought Rs.15,400/- + interest as per P-form


13 (1) ( e )

13. Date of hearing/place 10-01-2020 AT KOLKATA & 21-02-2020 AT DURGAPUR


For the Complainant Absent on both occasions

For the insurer Mr.Sunil Kumar,A.O.(Claims), Asansol Division




xv) That the Deceased Life Assured (DLA) purchased one immediate annuity (Jeevan Akshay VI) policy from LIC of India on 28-09-2016 with purchase price of Rs.5.00 lakh.

xvi) That the annuitant expired on 19-02-2018 and the nominee of the policy, the present Complainant, applied for return of purchase price from the insurer on 08-05-2018 intimating death of the annuitant.

xvii) That the insurer paid her Rs.4,99,682/- against the purchase price of the policy of Rs.5,00,000/- on 29-05-2018.

xviii) That it was not comprehensible to the Complainant how the final payment of a policy of sum assured Rs. 5,00,000 comes to Rs.4,99,682.

xix) That the Complainant wrote several times to the insurer for proper clarification of the deducted amount from the purchase price but did not receive any response from the insurer.

Being dissatisfied with the indifference of the insurer in providing the reason behind the deduction of

the aforementioned amount from the purchase price, the complainant has now approached this

forum for redressal of his grievance.



Name of Annuitant Mr. Madhusudan Banerjee

Name of the Nominee/relationship Ms. Manju Rani Banerjee (Wife)

Plan/Term/PPT Jeevan Akshay VI : 189 / 00 / 01

Date of Commencement 28-09-2016

Date of Vesting 28-09-2016

NCO/Purchase Price Rs. 5,00,000/-

Date of Death 19-02-2018

Annuity due on Amount of annuity paid

01-10-2017 upto 30-09-2017 Rs.(323* + 38,700)

Return of Purchase Price Rs. 5,00,000

Less broken period annuity paid on 01-10-2017 Rs. 318**

Amount paid to nominee Rs. 4,99,682

* Annuity for the Broken Period 28-09-2016 to 30-09-2016

** Deducted for the period 28-09-2017 to 30-09-2017 as the annuity payable up to 27-09-2017



Insurers’ argument: As per SCN received on 04-12-2018 the submission of the Insurance Company in this case is as follows :-

j) That the annuitant expired on 19-02-2018 and hence could not complete the cycle from 28-09-2017 to 27-07-2018. So, no annuity is payable for the period of 28-09-2017 to 19-02-2018.

k) That the annuity installment already paid from 28-09-2016 to 30-09-2016 for an amount of Rs.323/- and from 01-10-2016 to 30-09-2017 for an amount of Rs.38,700/-.

l) That annuity paid from 28-09-2017 to 30-09-2017 of Rs.318/- is not payable. m) That an amount of Rs. 4,99,682/- i.e. the purchase price of Rs.5 lakh less Rs.318/- was correctly

paid to the nominee on death of the annuitant on 19-02-2018.

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

payment of death claim on death of annuitant – 13 (1) (e)


iv) Complaint letter ii) P – form iii) Proposal papers iv) SCN


The Complainant was absent in the hearing at Kolkata on 10-01-2020 & also on 21-02-2020 at

Durgapur. However, the representative of the Insurance Company attended the hearing on both

occasions.

The representative of the Insurance Company explained that the annuitant expired on 19-02-2018

before completing the cycle from 28-09-2017 to 27-09-2018. Hence annuity for the period of 28-09-

2017 to 19-02-2018 is not payable as per terms and conditions of the policy. The return of purchase

price of Rs.5,00,000 was correctly paid to the nominee deducting the amount of Rs.318/-which is the

annuity already released for the period of 28-09-2017 to 30-09-2017 but not payable to him.

AWARD


representative of the Insurance Company during the course of hearing, it is observed that the date of

commencement of policy was 28-09-2016 and the annuitant expired on 19-02-2018. As per terms

and condition of the policy mentioned in the policy document “where the Annuity ceases on the

death of the Annuitant, no part of the said Annuity shall be payable or paid for such time as may

elapse between the date of payment immediately preceding the death of Annuitant and the day of

his/her death”... Hence the annuitant was entitled to receive annuity up to 27-09-2017 as per terms

and conditions of the policy. The Insurance Company paid the last annuity installment of

Rs.38,700/- for the period of 01-10-2016 to 30-09-2017. But the amount of annuity of Rs.318/- for

the period of 28-09-2017 to 30-09-2017 was not payable to the annuitant. Hence the said amount

was deducted while returning the purchase price of Rs. 5 lakh to the nominee of the policy as per

terms and conditions mentioned in the policy document. As such the amount paid by the insurer

to the nominee as final settlement of the policy is correct as per terms & condition of the plan of

the insurer.


Sd/-


INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE THE INSURANCE OMBUDSMAN, STATE OF WEST BENGAL, SIKIM, A&N ISLANDS

(UNDER RULE NO: 16(1)/17 of THE INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN – MR.P.K.RATH

CASE OF MR. DHIRAJ KUMAR SETHIA

V/S

LIC of INDIA




Mr.Dhiraj Kumar Sethia City Centre, 4th Floor, 19, Synagogue Street, Kolkata, West Bengal Pin – 700 001. Mobile No. 93828 54065


418048824 & 577127080 DETAILS ARE IN THE TABLE


Ms. Lalita Sethia (Deceased Life Assured ) ----------------------Do------------------------------

4. Name of the insurer LIC of INDIA (KMDO-I) 5. Date of Repudiation NA 6. Reason for repudiation NA 7. Date of receipt of the Complaint 01-10-2018 8. Nature of complaint Delay in settlement of Death Accident Benefit

9. Amount of Claim Rs.1,10,000 (DAB – Rs.55,000/- each for two policies)


11. Amount of relief sought Rs.1,10,000 (DAB) as per P-form


13 (1) ( a )


For the Complainant Mr.Dhiraj Kumar Sethia

For the insurer Mr. M. Srinivasa Rao, Manager (Claims), LICI, KMDO-I



xx) That the deceased Life Assured purchased two policies from LIC of India on 28-07-2004 & 28-07-2007 with identical sum assured of Rs.55,000/-.

xxi) That the deceased Life Assured expired on 19-03-2013 due to accident at Rajasthan. xxii) That the Insurance Company settled the basic sum assured to the nominee in August 2013.

xxiii) That the Complainant & the nominee of this case submitted the Death Certificate, PMR, Police Report etc. to LICI city Branch Office 1 on 11-02-2016 for accidental claim of these two policies.

xxiv) That the Insurance Company did not settle the accidental claim for two and half years without any proper reason.

xxv) That the Complainant approached the C.R.M. Department of the Divisional Office of the insurer with his grievance of non-settlement of accidental claim without any positive outcome.

Being dissatisfied with the insurer’s inordinate delay in settling the Death Accident Benefit, the



Policy No. 418048824 577127080

Name of Life Assured Lalita Sethia Lalita Sethia

Name of the


Dhiraj Kumar Sethia

(Husband)

Dhiraj Kumar Sethia

(Husband)

Plan/Term/PPT 014 / 21 / 21 014 / 21 / 21

DOC 28-07-2004 28-07-2007

Date of proposal 19-07-2004 31-07-2007

Premium/Mode 2,563/- (Yearly) 2,574/- (Yearly)

Sum Assured 55,000/- 55,000/-

Date of death 19-03-2013 19-03-2013

Duration of policy as on death of

LA 8 Y 7 M 21 D 5 Y 7 M 21 D

Amount of Basic SA paid / Date of

payment

79,035/-

30-08-2013

70,840/-

30-08-2013

Date of 1st complaint to

Ombudsman 01-10-2018 01-10-2018

18) Cause of Complaint: Delay in settlement of Death Accident Benefit.


Insurers’ argument: The submission of the Insurance Company is not available with us as no SCN has been received till date.

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

settlement of claim – 13 (1) (a)


v) Complaint letter ii) P – form iii) Proposal papers iv) SCN submitted on date of hearing


Both the parties attended the hearing at the Office of the Insurance Ombudsman, Kolkata on 06-02-

2020.

The Complainant stated that the deceased Life Assured, his wife, fell from roof accidentally at Rajasthan

and succumbed to death on 19-03-2013. The Insurance Company settled the basic sum assured but not

paying the accidental benefit in spite of submitting PMR, Police Report etc. confirming her accidental

death.

The representative of the Insurance Company expressed that they have settled the basic claim for both

the policies on 30-08-2013 and insisted on submission of certified copies of Police Final Report & Post

Mortem Report by the Complainant for considering the accidental claim against the policy. He however

mentioned that there is as such no dispute in this case.

AWARD


parties during the course of hearing, it is observed that the Insurance Company already settled the

basic death claim for these two policies to the nominee. The certified copies of Post Mortem Report

and the Police Final Report are required by the insurer to consider the accidental claim and it is

reported that they have not received those documents so far. The Complainant failed to furnish any

proof of submission of these two documents to the Insurance Company.






Ombudsman.

Sd/-


INSURANCE OMBUDSMAN





CASE OF MS. ALPANA MAITY

V/S

LIC of INDIA




Ms. Alpana Maity W/o. Late Biswanath Maity Vill-Sarbera, PO-Satbankura, WEST MIDNAPORE, West Bengal-721 253. Mobile No. 9800050406




Mr. Biswanath Maity (Deceased Life Assured ) ----------------------Do------------------------------

4. Name of the insurer LIC of INDIA (Kharagpur Division) 5. Date of Repudiation 26-03-2018 6. Reason for repudiation Suppression of material facts regarding age 7. Date of receipt of the Complaint 01-10-2018 8. Nature of complaint Dispute with regard to repudiation of claim 9. Amount of Claim Rs.1,60,000/- (Sum Assured)


11. Amount of relief sought Not mentioned in P-form


13 (1) ( B )


For the Complainant Ms.Alpana Maity & Ms.Riyashri Maity Dutta (Daughter of Complainant)

For the insurer Mr. Ashis Kumar Maity, A.O. (Claims), LICI,

Kharagpur Division 15 Complaint how disposed BY CONDUCTING HEARING 16 Date of Award/Order 14-02-2020


xxvi) That the deceased Life Assured purchased one Endowment Policy of Sum Assured of Rs.1.60 lakh from LIC of India on 28-01-2015 and paid three yearly premiums before his death on 16-12-2017.

xxvii) That the Life Assured expired before completion of 3 years from date of commence of policy. xxviii) That death claim was repudiated by the insurer with refund of premium on the ground of

furnishing false school certificate as proof of age by the Deceased Life Assured at the time of taking the policy.

xxix) That the deceased Life Assured merely passed 4th standard and signed all the documents unknowingly trusting on Agent. Even his false school certificate was allegedly arranged and produced by the Agent as proof of his age at the time of taking the policy without his knowledge.

xxx) That the Insurance Company did not verify the authenticity of the school certificate at the time of accepting the proposal and their decision to decline the death claim after receiving premium for 3 years on the basis of submission of false age proof is unfair and not justified.

xxxi) That the insurer would not raise any issue and settle the maturity claim for the policy if the deceased Life Assured survived till the date of maturity. But incidentally due to the happening of early death claim in this case, the insurer rejecting the claim showing trivial reasons.

xxxii) That the non-early death claim of the deceased Life Assured pertaining to his another policy was settled by the same insurer and the age difference of DLA in these two policies is of few months.

xxxiii) That Aadhar card of deceased Life Assured was also submitted to the insurer for verification of Age but the insurer did not respond to that.


relevant higher authorities of the insurer, the complainant has now approached this forum for

redressal of his grievance.



Name of Life Assured Biswanath Maity

Name of the Nominee/relationship Alpana Maity (Wife)

Plan/Term/PPT New Endowment

814 /16 / 16

DOC 28-01-2015

Premium/Mode 11,784.00 / Yearly

Sum Assured 1,60,000/-


Date of birth as recoded in policy 02-01-1961

Age at entry 54 years

Duration of policy as on death of LA 2 Years 10 Months 18 Days

Date of repudiation / rejection of claim 26-03-2018 (DO) 31-07-2018 (ZO)




Insurers’ argument: The submission of the Insurance Company as per their SCN received on 20-12-2018 is as follows:-

n) That the policy under complaint was accepted on the basis of School Certificate issued by

Teacher in-Charge of Nepura Prathamik Vidyalaya as age proof with date of birth 02-01-1961 which was self attested by DLA, verified by the concerned Agent and Development Officer.

o) That the teacher in-Charge of the said school confirmed in writing that the name of deceased Life Assured does not appear in their school records from the year 1961 & onward and the said school certificate is not authentic.

p) That as per report submitted by their investigating Officer the deceased Life Assured was a student of Sukchandpur Primary School and never studied in Nepura school as per version of the nominee, incidentally the Complainant of this case.

q) That the Employer’s certificate of the diseased Life Assured shows that he availed commuted leave for self illness from 01-02-2014 to 24-03-2014.

r) That the deceased Life Assured did not possess any standard age proof and his age was 54 years at the time of taking the policy as per Voter ID card which is a Non-standard age proof and no policy is issued on the basis of Non-standard age proof to a person with age at entry more than 50 years.

s) That the decision of repudiation of death claim under the above noted policy was taken on the basis of suppression of material facts regarding submission of fake age proof at the time of taking the policy as per provision of Section 45 of the Insurance Act 1938 and the premiums paid under the policies were paid to the claimant as full & final settlement of claim.

t) That the claimant sent representation for reconsideration of the claim to appellate authorities - ZOCDRC of the insurer, and the decision of repudiation was upheld by the committee which was duly communicated to the complainant vide letter dated 31-07-2018.

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



vi) Complaint letter ii) P – form iii) Proposal papers iv) SCN received on 20-12-2018



2020. Ms. Riyashri Maity Dutta, daughter of the Complainant, attended the hearing along with the

Complainant with the permission of Hon’ble Ombudsman.

She told that the Agent approached his father, the deceased Life Assured (DLA), and persuaded him to

take two policies, one on his own life and the other on the life of his wife. The age proof of his wife was

given to the Agent by him but he could not arrange for his own age proof in the form of school

certificate as he studied only upto Class IV in a school located at a faraway place from their present

residence. The Agent assured the DLA that he would manage the issue and he got the proposal

accepted by the insurer submitting a fabricated school certificate of DLA as age proof. The DLA signed

on the fake certificate as another form while signing on the proposal and other documents in this

regard. He trusted on the Agent, an authorized person of the insurer, and was not at all aware of this

misdeed conducted by the Agent on his behalf. She further pointed out that the Insurance Company

could have verified the genuineness of the school certificate before accepting the proposal and they are

questioning it now only to avoid the death claim. She argued that her father, the DLA, cannot be held

responsible for furnishing the fabricated age proof maneuvered by the Agent and the decision of the

insurer to reject the death claim with refund of premium is not acceptable to them.

The representative of the Insurance Company reiterated the points already mentioned in their SCN. He

clarified that they called for standard Age proof of deceased Life Assured from the claimant after

receiving the death claim but she could not produce the same. Though there is little difference in age of

the deceased Life Assured as recorded in this policy with that in respect of voter card, the voter card is

considered as non-standard age proof in LIC of India. The age at entry of deceased Life Assured was 54

years for the policy and non-standard age proofs like voter card is not acceptable as per rules for age at

entry above 50 years. Hence the policy could not be accepted at all at this age of deceased Life Assured

with voter card as age proof. The Life Assured expired after 2 Years 10 Months 18 Days of taking the

policy i.e. before completing 3 years and so the the death claim was repudiated with refund of premium

which has not been accepted by the Complainant.

AWARD


parties during the course of hearing, it is observed that the Agent of the Insurance Company

misguided the deceased Life Assured in submitting a fabricated age proof for acceptance of the

proposal. The deceased Life Assured was a lowly educated person and it was not possible for him to

understand the nuances of standard and non-standard age proof in terms of insurability of a person

of his age. He naturally depended on the Agent of the insurer on these issues. The Agent in this case

is a Chairman’s Club Member belonging to a respectable category as recognised by the Insurance

Company. He must know that policy with non-standard age proof is not acceptable for age at entry

more than 50 years. But still he had done the policy producing a fake school certificate of the

deceased Life Assured to facilitate his own cause sacrificing the interest of his customer. The misdeed

of the Agent becomes evident in the reporting of the Investigating Officer of the insurer who clearly

remarked that the Agent provided false School Certificate. Further the fabricated copy of the school

certificate was signed the Development Officer of the insurer without any verification. The Insurance

Company cannot disown the responsibility of the misdeed of their authorized Agent at the cost of the

interest of the claimant in this case. The difference of Age of the deceased Life Assured as recorded in

the policy and that as per voter card is negligible. Further the Life Assured expired after the

completion 2 years 10 months 18 days from date of commencement of risk. Hence the decision of

the Insurance Company to repudiate the death claim on the basis of submission of false age proof by

the deceased Life Assured is not justified as per provisions of Section 45 quoted in the policy

document.

As such the Insurance Company is instructed to settle the death claim in fovour of the nominee by

paying the basic Sum Assured with vested bonus etc. as per terms and condition of the policy.






Ombudsman.

Sd/-


INSURANCE OMBUDSMAN





CASE OF MS. SIPRA CHATTERJEE

V/S

LIC of INDIA




Ms. Sipra Chatterjee P-25, Uttarayan, R.N.Avenue, PO-Sodepur, Road No.5, Kolkata – 700 110, West Bengal. Mobile No. 8697553005


458739726, 458739422 & 458747130 DETAILS ARE IN THE TABLE


Mr. Subhendu Chatterjee (Deceased Life Assured ) ----------------------Do------------------------------

4. Name of the insurer LIC of INDIA (KMDO-I) 5. Date of Repudiation 17-06-2017 6. Reason for repudiation Suppression of material facts regarding health 7. Date of receipt of the Complaint 15-10-2018 8. Nature of complaint Dispute with regard to repudiation of claim 9. Amount of Claim Rs.17,00,000


11. Amount of relief sought Rs.17,00,000 as per P-form


13 (1) ( B )


For the Complainant Ms. Sipra Chatterjee

For the insurer Mr.M.S.Rao, Manager (Claims), LICI, KMDO-I




xxxiv) That the deceased Life Assured was an insurance minded person and he had purchased total 14 policies throughout his life span of which he had received maturity amounts for most of the policies. The Complainant also received death claim of 3 policies.

xxxv) That the above three policies under complaint were purchased from LIC of India which were inforce at the date of death of the life assured on 23-11-2016.

xxxvi) That the death claim of these three policies have been rejected by the Insurance Company on the ground of suppression of material fact regarding health at the time of taking these policies.


relevant higher authorities of the insurer, the complainant has now approached this forum for



Policy No. 458739422 458739726 458747130

Name of Life Assured Subhendu Chatterjee Subhendu Chatterjee Subhendu Chatterjee

Name of the


Sipra Chatterjee

(Wife)

Sipra Chatterjee

(Wife)

Sipra Chatterjee

(Wife)

Plan/Term/PPT New Endowment

814/15/15

Anmol Jeevan-2

822/10/10

Jeevan Rakshak

827/20/20

DOC 16-06-2014 17-06-2014 28-03-2015

Date of proposal 17-06-2014 17-06-2014 11-03-2015

Premium/Mode 28,424.00/ Yly 6,875.00 / Yly 7,689.00 / Yly

Sum Assured 4,00,000/- 11,00,000/- 2,00,000/-

Date of death 23-11-2016 23-11-2016 23-11-2016

Duration of policy as on

death of LA 2 Years 5 Months 2 Years 5 Months 1 Years 7 Months

Date of repudiation /

rejection of claim

17-06-2017 (DO)

06-11-2017 (ZO)

15-09-2018 (CO)

17-06-2017 (DO)

06-11-2017 (ZO)

15-09-2018 (CO)

17-06-2017 (DO)

06-11-2017 (ZO)

15-09-2018 (CO)

Date of 1st complaint to

Ombudsman 15-10-2018 15-10-2018 15-10-2018



Insurers’ argument: The submission of the Insurance Company as per SCN received on 28-01-2020 and the repudiation letter dated 17-06-2017 issued to the claimant is as follows:-

u) That these three policies have not completed 3 years from the dates of commencement of risk (16-06-2014, 17-06-2014 & 28-03-2015) as on date of death (23-11-2016) of the Life Assured.

v) That the deceased Life Assured was admitted to the R. N. Tagore Hospital on 05-03-2014 and the discharge summary dtd.10-03-2014 reveals that he was diagnosed with Pulmonary Koch’s & decompensated liver disease having a history of cough, blood tinged sputum, mild shortness of breath for two weeks.

w) That the deceased Life Assured was treated as outpatient in the same hospital on 24-03-2014 and was under treatment for the said ailment in May 2014, July 2014, Sept. 2014 & Dec.2014.

x) That the Employer’s certificate of the diseased Life Assured shows that he availed commuted leave for self illness from 01-02-2014 to 24-03-2014.

y) That the deceased Life Assured did not disclose these preexisting illnesses in proposal forms at the time taking these three policies.

z) That the decision of repudiation of death claim under the above noted policies were taken on 17-06-2017 on the basis of suppression of material facts regarding illness as per provision of Section 45 of the Insurance Act 1938 and the premiums paid under the policies were paid to the claimant as full & final settlement of claim.

aa) That the claimant sent representation for reconsideration of the claim to appellate authorities - ZOCDRC and COCDRC of the insurer, and the decision of repudiation was uphold by these committees duly communicated to the complainant vide letter dated 06-11-2017 & 15-09-2018

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



vii) Complaint letter ii) P – form iii) Proposal papers iv) SCN



2020.

The Complainant stated during the hearing that her husband, the deceased Life Assured of the three

policies under complaint, had insurance policies since 1992. He received the maturity claims for some

of the policies and the last one received by him in 2014. On receiving the maturity proceeds he was

persuaded by the Agent to take three more policies two in 2014 & one in 2015. One policy was taken

on the life of the Complainant as well in 2014. The Complainant received death claim for three policies

on the life of his deceased husband barring these policies under complaint.

The representative of the Insurance Company reiterated that the points they have already mentioned

in their SCN. It is pointed out that two of the thee policies under complaint were accepted under non-

medical scheme and for one policy with Sum Assured of Rs. 11 lakh was accepted after conducting

certain medical examinations as per norm. They have furnished treatment particulars of the deceased

Life Assured at R.N Tagore Hospital, Kolkata for Pulmonary Koch’s & decompensated liver prior to

taking these policies which was not disclosed by him in the proposal forms of these policies. Hence, the

claim was repudiated on the basis of suppression of material facts regarding health which had a strong

bearing on underwriting the risk.

The Hon’ble Ombudsman instructed the representative of the Insurance Company during the course of

hearing to furnish copies of the proposal forms for all three policies and the copies of the medical

reports for one policy which were submitted by the insurer on the following day.

AWARD


parties during the course of hearing, it is observed that the Deceased Life Aassured had been treated

for Pulmonary Koch’s & decompensated liver disease since 05.03.2014 i.e. 3 months to 1 year prior to

purchasing these three policies under complaint as documented by the Insurance Company with

treatment particulars. In fact he was under long term treatment regime while taking those policies.

This has been substantiated with certificate of his Employer, Custom House, Kolkata that he availed

leave from 10-10-2013 to 24-10-2013 and from 01-02-2014 to 24-03-2014 for self illness producing

medical certificate. The copies of proposal forms submitted by the insurer confirm Suppression of

material facts on part of the DLA. The span of all three policies was less than three years. As such the

decision of the Insurance Co. to repudiate the death claim of all three policies under complaint with

refund of premium is justified as per revised Section 45 of Insurance Act on the ground of suppression

of material facts as the Deceased Life Assured withheld the information that he had been suffering

from tuberculosis and allied liver ailments at the time of signing the proposals.

Hence, the complaint is treated as disposed of without providing any relief to the Complaint.





Ombudsman.

Sd/-


INSURANCE OMBUDSMAN





CASE OF MS. ANNA SARKER

V/S

LIC of INDIA




Ms. Anna Sarker Durga Charan Rakshit Road, Khalisani Bose Para, Chandannagar, Hooghly Pin – 712 136, West Bengal. Mobile No. 9903711552




Mr. Ranjan Sarkar (Deceased Life Assured ) ----------------------Do------------------------------

4. Name of the insurer LIC of INDIA (KMDO-I) 5. Date of Repudiation NA 6. Reason for repudiation NA 7. Date of receipt of the Complaint 07-05-2018 8. Nature of complaint Delay in settlement of Death Accident Benefit 9. Amount of Claim Rs.1,00,000 (DAB)


11. Amount of relief sought Rs.1,00,000 (DAB) + interest on Basic Sum Assured for delayed settlement as per P-form


13 (1) ( a )


For the Complainant Ms.Anna Sarker

For the insurer Mr. M. Srinivasa Rao, Manager (Claims) & Ms. Mohua Bhattacharya, Manager (CRM), LICI, KMDO-I




xxxvii) That a Jeevan Anand policy having Sum Assured of Rs.1 lakh was purchased by the deceased Life Assured on 31-12-2013 from LIC of India.

xxxviii) That the deceased Life Assured expired on 07-10-2014 and he was murdered as per Post Mortem Report. An FIR was lodged to the police accordingly for unnatural death.

xxxix) That the nominee and Complainant of this case submitted death claim on 01-12-2015 to the insurer.

xl) That the Insurance Company called for Final Verdict of the Court from the nominee for processing of the claim vide their letter dated 03-05-2017 & 07-07-2017.

xli) That the nominee could not furnish the same as it requires lot of time & money to obtain the same from the court of law.

xlii) That the death claim of Basic Sum Assured has been settled by the insurer after a long time. Being dissatisfied with the insurer’s inordinate delay in settling the Death Accident Benefit, the




Name of Life Assured Ranjan Kumar Sarkar

Name of the Nominee/relationship Anna Sarkar (Aunt)

Plan/Term/PPT Jeevan Anand

149 / 61 / 16

DOC 28-12-2013

Date of proposal 31-12-2013

Premium/Mode 3,965.00/ Half Yearly

Sum Assured 1,00,000/-


Duration of policy as on death of LA 9 Months 07 Days




Insurers’ argument: The submission of the Insurance Company is not available with us as no SCN has been received till date.

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

settlement of claim – 13 (1) (a)


viii) Complaint letter ii) P – form iii) Proposal papers iv) SCN submitted on date of hearing



2020.

The Complainant, nominee of the policy under complaint, stated that the deceased Life Assured was

her nephew i.e. son of her elder brother who is a widower and so she looked after the deceased Life

Assured since long. She told that her nephew was a promising electric light decorative artist who was

murdered by the miscreants. She submitted to the insurer the copy of the Final Report of the Police

investigation dated 05-01-2015 in which nine persons were charge sheeted by the police. But the

Insurance Company did not settle the Death Accident Benefit on the basis of the Police Final report and

insisted on submission of final verdict of the court in this respect. She mentioned that the basic Sum

Assured was also settled late by the insurer. So, she appealed for payment of interest on basic Sum

Assured along with Death Accident Benefit.

The representative of the Insurance Company submitted the SCN during course of hearing. He

questioned that the FIR on unnatural death of the deceased Life Assured was lodged by Ms.Sangeeta

Sarkar, the wife of deceased Life Assured. He pointed out that as per the PMR, FIR and the report of

Chandannagar PS, cause of death is murder by some miscreants with deadly weapon and gunshot

injury. Three accused persons were charge sheeted and the case is continuing. He confirmed the

settlement of death claim for basic Sum Assured including vested bonus of Rs.1,04,400/-to Ms.Anna

Sarkar, the registered nominee of the policy, on 15-06-2018. The late payment of the basic sum was

caused due to some discrepancy found in the name of deceased Life Assured, his father’s name, age

and address etc. The accident benefit can be considered only after receiving the final verdict of the

court in order to ascertain the motive of the murder.

The Complainant refuted that the police did not accept the FIR lodged by her. She also insisted that her

nephew was unmarried.

AWARD


parties during the course of hearing, it is observed that the deceased Life Assured was engaged in

decoration of electric light. He was allegedly murdered within 9 months of taking the policy. The

Basic SA has been settled by the Insurer to the Complainant who is the registered nominee of the

policy but the Death Accident Benefit has not yet been settled. The Insurer called for Final verdict of

the court of law to ascertain the motive of the murder. In Final Investigation Report four persons

were charge sheeted by the Police u/s 302/34 IPC 25/27 and five persons were charge sheeted u/s

120B IPC. This is a conclusive documentary proof of the cause of death of the deceased Life Assured

as murder in which there was no foul play on part of the nominee.

As such the Insurance Company is instructed to settle the Death Accident benefit of Rs.1 lakh to the

nominee/successor of the policy as the case may be on the basis of the charge sheet framed in Police

Final Report with interest on principal amount @2% above existing Bank rate for the period from

date of receipt of Final Police Report to actual date of payment.






Ombudsman.


INSURANCE OMBUDSMAN





CASE OF MR.BISWAJIT PANDIT

V/S

LIC of INDIA




Mr. Biswajit Pandit H/o. Late Karuna Pramanik (Pandit), Vill-Kalikakhali, PO- Math Chandipur, Dist : East Midnapore, West Bengal PIN : 721 659 Mobile No.9609462877




Ms.Karuna Pramanik (Pandit) (Deceased Life Assured) -------------------------Do--------------------------

4. Name of the insurer LIC of INDIA (Kharagpur Division)

5. Date of Repudiation Not Applicable 6. Reason for repudiation Not Applicable 7. Date of receipt of the Complaint 23-03-2018

8. Nature of complaint Dispute with regard to rejection of death claim due to lapsation of SSS policy caused by gap premiums

9. Amount of Claim Rs 88,000/-


11. Amount of relief sought Rs 88,000/- as per P-form submitted


13 (1) ( i )


For the Complainant Mr. Biswajit Pandit

For the insurer Mr.Ashis Kumar Maity, A.O. (Claims), LICI, Kharagpur Division


17) Brief Facts of the Case: The complainant has alleged the following:- xliii) The death claim on the life of Late Karuna Pramanik (Pandit) under Policy No.432764095 was

rejected by LIC of India wrongly on the ground that it was in lapsed condition as on date of her death.

xliv) It is alleged that the policy was in force but the Insurance Company rejected the death claim on wrong ground.

xlv) The Complainant, the husband of the deceased Life Assured, is the legal heir as per succession certificate produced by him.

Being dissatisfied with the insurer’s decision of rejecting the death claim, the complainant has now approached this forum for redressal of his grievance. Details of the policy issued:


Name of Life Assured Ms.Karuna Pramanik (Pandit)

Name of the legal heir/relationship Mr. Biswajit Pandit (Husband)

Name of the Nominee/relationship Mr.Surya Kr Pramanik (Brother)

Plan/Term/PPT Money Back 75 / 20 /20

DOC 28-03-1999

Premium/Mode Rs.539/- (SSS Mly)

Sum Assured Rs. 88,000/-

First Unpaid Premium (FUP) of policy 28-09-2002


Gap premium from-to (No. of gap premium) 28-04-1999 to 28-05-2000 (14)

Total duration of policy/Effective duration 42 months/ (42-14)=28 months

Effective FUP of policy 28-07-2001

Status of the policy as on date of death Lapsed without acquiring PUV

18) Cause of Complaint: Due to rejection of death claim.


Insurers’ argument: As per SCN received from the insurer :-

bb) That the Deceased Life Assured (DLA) was a Primary School Teacher who committed suicide by hanging herself on 15-09-2002.

cc) That valid nomination subsists for this policy in the name of Mr. Surya Kr. Pramanik, brother of the DLA. However, Mr. Biswajit Pandit, husband of the DLA, was authorized to receive the claim proceeds for all six policies of DLA according to succession certificate issued by court of law.

dd) That all six policies were under Salary Savings Scheme and five policies except the present one under complaint was in force without any gap premium as on date of death and death claims were settled accordingly.

ee) That the present policy under complaint had 14 gaps from 28-04-1999 to 28-05-2000. Hence the original date of First Unpaid Premium (FUP) of 28-09-2002 was shifted back for 14 months to 28-07-2001 as per terms and condition of the Corporation.

ff) That the policy was in lapsed condition without acquiring Paid up Value as premium paid for only 28 months i.e. less than 3 years as on date of death (15-09-2002) and the claim was rejected accordingly.

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

of death claim by insurer though the policy was allegedly in-force as on date of death of Life Assured –

13 (1) (i)


ix) Complaint letter ii) P – form iii) Proposal papers iv) SCN


Both the parties attended the hearing at the Office of the Insurance Ombudsman on 06-02-2020.

The Complainant stated that he could submit the death claim to the Insurance Company only after

receiving the succession certificate in his favour from the court on 21-01-2015 and this also the cause of

delay in filing the complaint in turn. He stated that the policy was in force when his wife, the deceased

Life Assured, committed suicide on 15-09-2002. The premium was paid up to 28-09-2002 according to

the policy status report generated by the insurer. Hence, the decision of the Insurance Company to

reject the death claim is not at all justified.

The representative of the Insurance Company explained that though the policy was apparently in force

up to 28-09-2002, there was gap of 14 monthly installment of premium prior to the date of first unpaid

premium in the said Salary Savings Scheme policy. As the no. of monthly gap premium installments are

more than twelve and fourteen to be specific, the effective date of first unpaid premium was shifted

back for 14 months to 28-07-2001 as per rule. Thus, the policy was in lapsed condition at the date of

death of the deceased Life Assured and the death claim was rejected accordingly.

AWARD


parties during the course of hearing, it is observed that the deceased Life Assured was a primary

school teacher who committed suicide by hanging herself. As per the copy of the policy document,

valid nomination of the policy subsisted in favour of Mr.Surya Kanta Pramanik, the brother of the

Deceased Life Assured. But the Complainant furnished Succession Certificate in his favour to establish

his right to receive the death claim proceeds of the policy under complaint.

The premium had been paid for 28 months i.e. less than 3 years excluding the gap premium and so no

paid up value was acquired by the policy. The effective date of first unpaid premium was shifted back

to 28-07-2001 according to the existing rules of the insurer. Thus the policy was in lapsed condition at

the date of death of the deceased Life Assured. As such the decision of the Insurance Company to

reject the death claim is justified.






Ombudsman.


INSURANCE OMBUDSMAN



PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WEST BENGAL, SIKIM, A&N ISLANDS

(UNDER RULE NO: 16(1)/17 of THE INSURANCE OMBUDSMAN RULES, 2017)

OMBUDSMAN : Shri P.K. RATH

CASE OF DHIRENDRA NATH DEY V/S LIFE INSURANCE CORPORATION OF INDIA



1. Name & Address of the Complainant Mr Dhirendra Nath Dey

H/o Late Smt lakhmi Dey,

Vivekananda Para, PO : Bairatiguri,

PIN : 735210, Dist : Jalpaiguri, West Bengal

2. Policy No:

Policy Type/Duration/Period

445973713

DETAILS ARE IN THE TABLE

3. Name of the Insured/LA

Name of the proposer

Mrs Lakhmi Dey (Deceased)

Self

4. Name of the insurer Life Insurance Corporation of India, Jalpaiguri Div.

5. Date of Repudiation Not Applicable

6. Reason for repudiation Not Applicable


8. Nature of complaint Dispute with regard to repudiation of claim

9. Amount of Claim Rs 1,00,000/-


11. Amount of relief sought Rs 1,00,000/- + Bonus


Insurance Ombudsman Rules’ 2017

13 (1) ( C )

13. Date of hearing/place On 07-02-2020 at SILIGURI


For the Complainant Mr Dhirendra Nath Dey

For the insurer Mr Ashoke Paul

15 Complaint how disposed BY CONDUCTING HEARING

16 Date of Award/Order 17-02-2020


Pol No L.A. PLAN DOC Premium

(yly)

Term

/PPT

1ST Comp to

Ins Co

445973713 Lakhmi Dey Endowment Assu. 28-01-2016 Rs 5490 21/21 02-04-2019

Sum Assured : Rs 1,00,000/-

Date of death of Life Assured : 01-02-2016

Duration of the policy : 2 days

Date of repudiation of claim : 02-02-2019

Date of representation against repudiation : 02-04-2019


xlvi) That the death claim of the above insurance policy on the life of his deceased wife has been repudiated by Jalpaiguri divisional Office of LICI vide their letter dated 02-02-2019.

xlvii) That in the said letter the insurance company has mentioned that as the Deceased Life Assured (DLA) had replied in the negative while answering all questions in Q No 11 (a) to (h) of the relevant proposal form and that all those answers were false.

xlviii) That the insurer has mentioned treatment sheet of Jalpaiguri Sadar Hospital dated 01-02-2016 wherein it had been stated that “The DLA was a known patient of HTN from year 2009 and the DLA had history of Anemia, IHD, RTI.”

xlix) That he is unable to understand where from such inference had been drawn by Jalpaiguri Sadar Hospital as being husband, he has spent considerable time with his wife and that his wife had never suffered from the diseases mentioned in the treatment sheet of Jalpaiguri Sadar hospital. The inference arrived at by the Jalpaiguri Sadar Hospital was not drawn from any cogent evidence.

l) The death claim against another policy (no 458245402) having D.O.C. 28-12-2015 has been admitted by the same office of the insurance company. As such there is contradictory approach for two early claim policies.

As such, the complainant has now approached this forum for redressal of his grievance.

18) Cause of Complaint: Due to misselling of policy.

Complainants argument : In point No. 17 it is mentioned categorically.

Insurers’ argument: As per SCN received from the insurance company – i) The proposal was signed on 29-01-2016 and the Deceased Life Assured (DLA) died on 01-

02-2016 due to cardigenic shock. The claimant was asked to submit treatment particulars of DLAS on 25-07-2017 but he replied that DLA did not take any treatment, therefore he was unable to submit the same.

ii) Letters were written to Sadar Hospital Jalpaiguri where the DLA died to furnish the case history / Bed Head Ticket and accordingly the hospital responded. As per hospital case history sheet –

a. DLA was known hypertensive from 2009. b. DLA has history of HTN, Anemia, RTIACS, Sepsis c. DLA was admitted on 01-02-2016 with complaint of respiratory distress and chest

pain for 4 days. iii) Date of admission in Sadar Hospital on 01-02-2016 at 2.55 pm referred from Dhupguri Rural

Hospital where she was admitted on 31-01-2016. iv) OPD/Emergency ticket of Dhupguri Rural Hospital reveals that the DLA was admitted on 31-

01-2016 with a complain of chest pain with respiratory distress 4 days. Referral card of Dhupguri Hospital reveals that Clinical Diagnosis was IHD/T-2 DM, HTN.

v) DLA suppressed the fact of ailment at the time of taking the policy. Hence the claim has been repudiated for suppression of material facts and the same was intimated to claimant on 02-02-2019.

vi) Subsequently the claimant had approached Zonal Office Claims Dispute Redressal Committee (ZOCDRC) for review of the case. The ZOCDRC has upheld the decision of repudiation.

vii) As regards the other policy no 458245402 (DOC – 28-12-2015), the claim was admitted since there was no record of ailment at the time of taking the policy. But as regards policy no 445973713 there is clear evidence of the fact that the DLA was ill for 4 days before hospitalization at Sadar Hospital, Jalpaiguri on 01-02-2016 referred by Dhupguri Hospital where she was admitted on 31-01-2016.


over premium paid or payable in terms of insurance policy – 13 (1) (c)


x) Complaint letter ii) P – form iii) Proposal papers iv) SCN li) Treatment sheet of Jalpaiguri Sadar Hospital dated 01-02-2016. lii) OPD ticket of Dhupguri Hospital dated 31-01-2016.

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

Both the parties were present and participated in the hearing.

The complainant submitted that he runs a small business of fruits. He stated that his deceased wide

was not suffering from any serious disease and that she only used to take medicines for Hypertension

infrequently.

The representative of the insurance company repeated what has been already stated in their Self

Contained Note (SCN) submitted to this office. He stressed on the fact that the relevant hospital

documents conclusively prove that the deceased life assured had suppressed material facts pertaining

to her suffering from hypertension and other ailments prior to purchase of the policy.

AWARD

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

during the course of hearing and after going through the documents on record it is observed that

scrutiny of the treatment sheet / case history sheet of Sadar Hospital, Jalpaiguri dated 01-02-2016

reveals that the DLA had history of (H/O) Hypertension (HTN), Ischemic Heart Disease (IHD), RTI, ACS,

Anemia and Sepsis. As the proposal paper was signed on 29-01-2016 i.e. just three days ago, this fact

has great implications as the DLA has not stated about her illness in the relevant proposal form. The

DLA was admitted to the OPD/emergency of Dhupguri hospital on 31-01-2016 i.e. only 2 days prior to

signing the proposal with complaint of chest pain and respiratory distress.

From the above, though it is not clearly reflected as to the exact period of onset of the diseases

mentioned in the Treatment sheet / case history sheet of Sadar Hospital, Jalpaiguri, it is obvious that

they were present at the time the proposal form was being filled up by the DLA as it was just 3 / 4

days back. However it cannot be established that the DLA had intentionally and knowingly

suppressed material facts pertaining to her diseases with the malafide intent of defrauding the

insurer.

Hence the repudiation of claim made by the Insurance Company is upheld and the Insurer is directed

to refund all the premiums collected under the policy.

Hence, the complaint is dismissed.

Dated at KOLKATA on 17th day of February’ 2020.

P.K. RATH

INSURANCE OMBUDSMAN

FOR THE STATE OF WEST BENGAL, SIKKIM and A&N ISLANDS


(UNDER RULE NO: 16(1)/17 of THE INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN – SHRI P.K. RATH

CASE OF ANIL AGARWAL V/S LIC of INDIA

COMPLAINT REF: NO: KOL-L-029-1920-0960 (Old No. KOL-L-029-1819-0091) AWARD NO: IO/KOL/A/LI/ 0573 /2019-2020

1. Name & Address of the Complainant Mr Anil Agarwal C/o Tekchand Chhabilchand, Shivaji Road, Khalpara,

Opp. Jaihind Building, Dist : Darjeeling, Siliguri, PIN : 734005




Mr Radharaman Pal (Deceased Life Assured - DLA) Self

4. Name of the insurer LIC of INDIA (Jalpaiguri Division)

5. Date of Repudiation Not Applicable 6. Reason for repudiation Not Applicable 7. Date of receipt of the Complaint Current complaint transferred from

OIO, Jaipur, Rajasthan on 27-12-2019 (Prev. Comp. Recd. On 15-05-2018)

8. Nature of complaint Dispute with regard to repudiation of claim 9. Amount of Claim Rs 25,00,000/-


11. Amount of relief sought Rs 25,00,000/- + Interest @ 13% 12. Complaint registered under

Insurance Ombudsman Rules’ 2017 13 (1) ( B )

13. Date of hearing/place 07-02-2020 at SILIGURI 14. Representation at the hearing

For the Complainant Mr Sunil Kumar Agarwal

For the insurer Mr Ashoke Paul


17) Brief Facts of the Case: Pol No L.A. PLAN DOC Premium

(yly) Term /PPT

1ST Comp /Representation

to GRO of Ins. Co

458255518 Mr Radharaman Pal

Term Insurance

04-08-2015 Rs 22,075/- 18/18 yrs 07-07-2017

Name of Policy / Type : Amulaya Jeevan 2 / Term Insurance Table/Term/PPT : 823/18/18 Death Sum Assured : Rs 25,00,000/- Last due paid : 08/2016

FUP of policy : 08/2017 Date of death : 02-09-2016

Date of submission of claim : 07-07-2017 Status of the policy as on date of death : Inforce Claim status : Death claim repudiated

Date of repudiation / rejection of claim : 06-06-2018 The complainant has alleged the following:-

liii) That the above policy had been purchased by late Radharaman Pal from LICI on 04-08-2015. Required medical tests were duly performed before issuing the policy.

liv) That the policy was absolutely assigned in favour of Anil Agarwal (complainant) on 16-11-2015 by the deceased life assured (DLA) for loan liabilities by executing the assignment on a Non-Judicial stamp paper.

lv) That the insurer had demanded reasons, causes & legal aspects with documentation. The same were submitted to the servicing branch office of LICI. Thereafter the assignment has been duly recorded in the books of the insurer (LICI) on 15-12-2015 and the policy is absolutely assigned in favour of the complainant.

lvi) That the assignor Radharaman Pal died on 02-09-2016 and thereafter the absolute assignee – Anil Agarwal – submitted relevant documents towards death claim to the insurer on 11-07-2017. Thereafter certain other requirements were called for by the insurer and the same too have been submitted to them.

lvii) Thereafter the insurer called for the following documents – a. Third party declaration before Executive Magistrate. b. Sale deed of land for which the loan was availed and the policy was assigned. c. Declaration from wife of the DLA.

All the above three documents have been duly submitted to the insurer.

lviii) That after submitting all the required documents and repeatedly taking up the matter with the concerned authorities the claim has been repudiated by the insurance company.

Being dissatisfied with this repudiation made by the insurer, the complainant has now approached

this forum for redressal of his grievance.

18) Cause of Complaint: Due to repudiation of death claim.


Insurers’ argument: As per SCN received from the insurer :- gg) The nominee under the policy is Smt Bijaya Pal, wife of the DLA but the policy was absolutely

assigned in favour of Sri Anil Agarwal – the complainant on 15-12-2015 just three months after the DOC of the policy.

hh) The DLA died on 02-09-2016 and the assignee Anil Agarwal applied for death claim on 07-07-2017.

ii) The age proof submitted by the DLA at the time of taking the policy was School Transfer Certificate (T.C.) of Jagdish Chandra Bidyapith. But after investigations it is revealed that the DLA never studied in the school. The fact has been stated in writing by the present Head Master of Jagdish Chandra Bidyapith vide his letter dated 23-05-2018 wherein it is mentioned that as per School’s Admission Register the DLA never studied in the school between 1963 and 1979. So the question of issuing the TC does not arise. Photocopy of the letter issued by the present headmaster as well as that of the TC of the DLA have been submitted along with the SCN.

jj) Besides, investigations have also revealed that the T.C. submitted by the DLA does not resemble the TCs issued by the school authority. Photocopy of three such TCs have also been submitted along with SCN.

kk) As such, the claim has been repudiated on the ground of suppression of material facts for submitting false TC as age proof at the time of purchasing the policy to defraud the Corporation.

ll) Besides the claim is also repudiated on the ground of suspect of Insurance Trading to benefit the claimant by inducing absolute assignment through fabricated documents.

mm) The above reasons for repudiation of death claim have been intimated to the complainant vide letter dated 06-06-2018.

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



xi) Complaint letter ii) P – form iii) Proposal papers iv) SCN v) Affidavit dated 09-09-2019. vi) Copies of correspondences

vii) Copy of plan details of IRDA approved product (UIN NO.512N286V01)

pertaining to LIC’s Amulaya Jeevan –II

viii) Copy letter dated 22-01-2020 issued by PNB, Nehru Road Branch, Siliguri.

ix) Copy of the alternate set of proposal papers (submitted by the complainant’s authorised

representative)


Both the parties were present and participated in the hearing. The complainant was represented by

his authorised representative and elder brother named in 14 above and the insurance company was

represented by its official named in 14 above.

The representative of the complainant submitted that his brother is suffering from neurological

disorder and is undergoing treatment for the same. He submitted that PAN card was originally

submitted along with the proposal form as age proof and not School Certificate. The complainant’s

representative then repeated the allegations that the complaint has mentioned in his written

complaint letter submitted to this office. He stated that he has copy of the relevant proposal form on

the basis of which the policy in this instant case was issued and he submitted the same during the

course of hearing.

The representative of the insurance company submitted that repudiation of claim was done due to

suppression of material facts as because the deceased life assured (DLA) Mr Radharaman Pal had

submitted fabricated documents pertaining to his School Transfer Certificate. He also submitted that

there is a strong ground to suspect that this is a case of Trading in Insurance Policy with the malafide

intent of benefitting the complainant as they have documentary evidence in the form of letter issued

by the concerned DD Issuing Bank which shows that the Demand Draft (DD) utilized towards the first

premium of the policy was not purchased by the policyholder (DLA) but it was funded by the

complainant. The insurer’s representative submitted copy of the relevant letter during the course of

hearing.

AWARD


during the course of hearing and after going through the documents on record it is observed that the

complainant, in his initial complaint letter dated 10-05-2018 submitted to this forum had

complained regarding delay in settlement of death claim. But subsequently on receipt of SCN from

the insurer it is observed that the claim has been repudiated by the insurer vide letter dated 06-06-

2018. The ground on which the insurer has repudiated the claim is based on submission of

fabricated age proof document. In this context, on comparison of the photocopies of the School

Transfer Certificate (TC) submitted by the DLA and those obtained from the school authorities by

the insurer, the following are observed :-

a) The name of the school as printed on the DLA’s TC is Jagadish Chandra Bidyapith whereas

in the other TCs the name is Siliguri Jagadish Chandra Bidyapith.

b) The DLA’s TC does not bear any printed serial number whereas in the other TCs printed

serial number is present.

c) The present headmaster of Siliguri Jagdish Chandra Bidyapith has issued letter dated 23-05-

2018 wherein it is clearly mentioned that there was no student by the name Radharaman Pal,

S/o Harendra Chandra Pal as per the school admission register and other school records in

the period from 1963 to 1979.

From the above, prima facie, it is established that the School Transfer Certificate (TC) document

submitted by the DLA towards admission of his age is fabricated and forged and the same has not

been issued by the concerned school. Thus the malafide intent of the deceased life assured Mr

Radharaman Pal is quite evident.

The repudiation of claim was made by the Jalpaiguri Divisional Office of LICI and subsequently

the same has been upheld by the Zonal Office Claims Dispute Redressal Committee (ZOCDRC) of

the insurance company which is headed by a retired High Court Judge. Thereafter the

complainant had appealed to the insurer’s highest office before the Central Office Claim Disputes

Redressal Committee (COCDRC) which is headed by a retired Supreme Court Judge. The

COCDRC too has upheld the repudiation of death claim and the same was conveyed to the

complainant cum assignee.

The complainant (absolute assignee) had initially submitted his complaint at Kolkata Centre of

Office of The Insurance Ombudsman and the same was registered at Kolkata Centre vide

complaint number KOL-L-029-1819-0091 on 15-05-2018. But subsequently he had applied for

transferring the complaint to Jaipur on the ground that he has shifted his place of residence from

Siliguri (West Bengal) to Jaipur (Rajasthan) for reasons of my business / profession. As such, the

complaint was transferred to OIO, Jaipur. Thereafter, OIO Jaipur had asked for proof of address

of present residence from the complainant Mr Anil Agarwal and in response he had submitted an

affidavit dated 09-09-2019 as proof of residence wherein he had confirmed that he has shifted his

place of residence from Siliguri, West Bengal to Srikaranpur, Dist : Sriganganagar, Rajasthan.

Further he has also submitted copy of rent agreement in respect of his residence at Sriganganagar,

Rajasthan to OIO, Jaipur. Thereafter the complaint was scheduled for hearing at OIO Jaipur on

09-12-2019.

However on the scheduled hearing date, the complainant did not attend the hearing himself due to

medical reasons and instead sent his elder brother Mr Sunil Agarwal, with the request that his

brother be allowed to attend the hearing on his behalf. The same was permitted by the competent

authority at Jaipur. The hearing of the complaint was held on 10-12-2019 at Jaipur and award was

issued vide Award No. IO/JPR/A/LI/0087/2019-20. Scrutiny of text of the award reveals that the

complainant’s representative had submitted before the Hon’ble Ombudsman at Jaipur that the

complaint had been transferred from Kolkata to Jaipur because of non-availability of the

Insurance Ombudsman at Kolkata for the purpose of early hearing. The complainant’s

representative stated that he and his brother reside in Siliguri and stated that it would be

convenient for them to travel to Kolkata for the hearing rather than to Rajasthan. In lieu of the

aforementioned submission, the Hon’ble Ombudsman Jaipur has again transferred the case to

OIO Kolkata Centre and has closed the complaint at OIO Jaipur Centre.

From the above it is clear that the complainant had misguided Office of the Insurance

Ombudsman, Kolkata about shifting of his residence from Siliguri to Jaipur and had stated false

things in his transfer request letter dated 21-07-2019. Moreover, although in the hearing which was

held at Jaipur the complainant’s representative had submitted that it would be convenient for

them to attend hearing at Kolkata, this office has received a letter from the complainant on 03-02-

2020 wherein he has requested that his elder brother Mr Sunil Kumar Agarwal be allowed to

attend the hearing on his behalf as he is himself unable to attend the hearing due to medical

necessities. Thus again the complainant has expressed his unwillingness to attend the hearing

personally and there seems to be an element of suspicion in his repeated attempts to avoid being

personally present at the hearing.

Further, when the complaint was initially lodged with OIO Kolkata, the insurer LICI had

submitted to Kolkata centre copy of the proposal form of the policy in this instant case. Perusal of

the same shows that nature of age-proof submitted is “S/C” i.e. School Certificate. But surprisingly

when the case was transferred back to Kolkata from Jaipur and second heaing of the case was held

on 07-02-2020, the complainant’s representative submitted a different proposal form wherein the

nature of age-proof is recorded as “PAN CARD”. The complainant’s representative has submitted

that the insurance company had repudiated the claim on wrong grounds as the age proof

submitted by the DLA was Pan Card and not School Certificate. Careful comparison of both the

proposal forms reveal the following;-

Field Description Earlier/Older Proposal Form Later/New Proposal Form

Proposal Number- Present (4927) Absent (Blank/No value)

B.O.C. No.- Present (5179) Absent (Blank/No value)

BOC Date- Present (01-08-2015) Absent (Blank/No value)

Deposit Amount- Present (24000/-) Absent (Blank/No value)

Division- Present (Jalpaiguri) Absent (Blank/No value)

Branch Office- Present (453) Absent (Blank/No value)

DO code- Present (426) Absent (Blank/No value)

Agent code- Present (06666/453/426) Absent (Blank/No value)

Edu. Qly.- Upto Class VIII Upto Class V

Annual income- Rs 3 lac Upto 3 lac

Wife’s age- Present (41 yrs) Absent (Blank/No value)

Bank Acc.- Present (Central Bank) Absent (Blank/No value)

Signature of witness- Present (Atanu Roy -Agent) Absent (Blank/No value)

The absence of values in so many vital fields of the new/alternate proposal form submitted by the

complainant’s representative confirms the fact that the alternate proposal form is an unrelated

document submitted by the complainant and/or his authorised representative and the same has not

been used by the Insurance Company in assessing the risk on the life of late Mr Radharaman Pal

at the time of policy issue.

Perusal of the letter dated 22-01-2020 issued by Punjab National bank, Nehru Road Branch,

Siliguri clearly stated that the DD No. UMB 409515 of Rs 24,000/- has been purchased by Mr Anil

Agarwal through cheque no FSL 261804 from Bank A/c No. 3132000100149666. The said letter of

the DD issuing Bank also mentions the PAN number of the Purchaser as ACBPA5524G. Thus it is

obvious that the purchase of the policy by the deceased life assured was funded by the complainant

who was at that time i.e. in 08/2015, only a third party in respect of policy number 458255518. That

the same third party and the present complainant Mr Anil Agarwal, became the absolute assignee

of the policy only four months later in 12/2015, speaks volumes about the malafide intent involved

in the entire sequence of events.

Thus prima facie, the fraudulent intention of the Deceased Life Assured (DLA) Mr Radharaman

Pal in respect of purchasing the policy, by using a false and fabricated age proof document, for the

purpose of defrauding the insurance company is established. Hence repudiation of claim by the

insurer on the ground of fraudulent suppression of material facts regarding the age of the deceased

life assured is justified as per Section 45 of the Insurance Laws (Amendment) Act’ 2015 and the

same is upheld. However, very serious view is taken against the complainant Mr Anil Agarwal with

respect to his action of misleading this office with the deceptive application of change of his

residence from Siliguri, West Bengal to Jaipur, Rajasthan with the intent of getting the complaint

transferred out of Kolkata Centre of the Office of the Insurance Ombudsman.

Hence, the complaint is disposed of without any relief to the complainant.

Dated at KOLKATA on 18th day of February’ 2020

INSURANCE OMBUDSMAN


PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN STATES OF WEST BENGAL, SIKKIM AND UT OF ANDAMAN & NICOBER ISLANDS

(UNDER RULE NO: 16(1)/17 of INSURANCE OMUDSMAN RULES, 2017) OMBUDSMAN – SHRI PRADIP KUMAR RATH

CASE OF – SMT. CHANDANA BIJALI

V/S MAX LIFE INSURANCE CO. LTD.

COMPLAINT REF NO: KOL-L-032-1819-0596 AWARD NO:IO / KOL/A/LI/ 0550 /2019-2020

1. Name & Address of the Complainant SMT. CHANDANA BIJALI C/O - SWAPAN BIJALI, ACHINTA NAGAR, SOUTH 24 PARGANAS, PIN – 743383, WEST BENGAL MOB. NO : 8972366523

2. Policy Nos. Type of Policy Duration of policy/Policy period

866058639 MAX NEW YORK LIFE GUARANTEED MONTHLY INCOME PLAN 6 YEAR

3.

Name of the insured Name of the Policy Holder

TAPAS KUMAR BISWAS SELF

4. Name & address of the insurer MAX LIFE INSURANCE CO. LTD.

5. Date of Repudiation ----- 6. Date of lodgement of complaint to

Insurer 28/09/2018

7. Date of receipt of the Complaint in this forum

23/10/2018

8. Nature of complaint DELAY IN SETTLEMENT OF DEATH CLAIM.

9. Amount of Claim RS.388320/

10. Date of Partial Settlement ---- 11. Amount of relief sought RS.388320/ 12. Complaint registered under IOR 2017 13(1)(a)

13. Date of hearing/place 04/02/2020 AT KOLKATA 14. Representation at the hearing For the Complainant ABSENT For the insurer SANDIPAN BANERJI 15 Complaint how disposed BY CONDUCTING HEARING AT KOLKATA

16 Date of Award/Order 11/02/2020

17 Brief Facts of the Case

POLICY NO. D.O.C. NAME T/PPT Premium Including Tax

POL. BOND RECEIVED

866058639

21/06/2012

TAPAS KUMAR BISWAS

16/06

Rs. 49359/

RECEIVED.

18.COMPLAINANT SUBMISSION: Complainant alleged the following points-

a) That she is the only Nominee and Claimant of the above death claim case but the Insurer is not settling the Death Claim payment in spite of her submission all necessary papers and requirements as per demand of the Insurance Company.

b) That the representative of the Insurance Company made an investigation on this death claim successfully but still they are not taking any steps to settle the death claim.

c) That the sales representative of the company is enforcing her to do a new policy with the claim amount but she is unable to do so due to her financial conditions.

d) That, she has already received 3 death claims from LICI under policy numbers 494823862, 495621852 & 495621853 with total amount Rs.471000/ & in all the 3 policies, she was the nominee. She also pointed out that the last 2 policies were introduced in the year 2014 ie after 2 years of the policy introduced in Max Life.

e) That she made appeal to Insurance Company on 28/09/2018 for settlement of claims but the deputy manager of the company insisted her to submit succession certificate from competent court of law for further processing of claim.

f) That she wrote letter to deputy manager on 28/09/2018 to let her know the reason behind non-payment, stating whether it was on the ground of rival claim or not but the company did not reply to her query.

g) So, she complained in this forum to settle her claim.

Insurers’ argument: SCN dated 11/07/2019 stated the following-

a) That the complainant is making a deliberate attempt of extortion against the Insurer by making false and baseless allegations.

b) That the policy holder nominated initially Mr. Rajesh Pathak, stated to be his friend as his nominee but subsequently he changed his nominee to one Ms. Chandana Bijali,, the complainant, stated to be his niece.

c) That they later on came to know that Chandana Bijali was the maid of the policy holder and as such the relationship of the nominee was not confirmed.

d) That, accordingly, the death clam was closed for want of succession certificate on 30/07/2018 and the same was intimated to the complainant vide letter dated 30/07/2018.

e) That, on 31/01/2018, they received one letter from Mr. Tamal Biswas, claiming himself to be the only legal heir(son), submitted death claim in his favour along with an affidavit of Seal Dah Court in support of his claim.

f) That, they are not in a position to settle the death claim due to non submission of Succession certificate by the complainant as well as for rival claim.

19) Reason for Registration of Complaint: Scope of The IOR, 2017 under rule 13

(1)(a).

20) The following documents were placed for perusal by Complainant.

a) Annexure – VI-A, b) Complaint letter, c) Reply of the Insurer, d) Copy of proposal e)

Copy of Policy document & f) SCN

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

Complainant’s Submission: The claimant was absent on the date of Hearing.

Insurer’s Submission: The representative of the Insurer repeated all the points as

mentioned in their SCN. He categorically informed about the necessity of succession certificate

in this case to settle the case in view of no blood relation of the nominee to the deceased and

also for the lodgment of claim by the son of the deceased as claiming vide court affid avid

dated 31/10/2018.

AWARD

Taking into account the facts and circumstances of the case and after going through the documents

on record and the submissions made by the representative of the Insurer during the course of

hearing, it is observed that the complaint of death claim is pending due to nonsubmission of

succession certificate in a background of rival claim lodged by Mr. Tamal Biswas, claiming to be the

son of the deceased vide court affidavit dated 30/01/2018.

Considering all the above, the Insurer is advised to settle the case as per law and the complaint is

dismissed at our end without giving any benefit to the complainant.

Dated at Kolkata, the 11th day of February 2020.

S/d

P. K. RATH

INSURANCE OMBUDSMAN


SIKKIM AND UT OF A & N ISLANDS

PROCEEDINGS BEFORE


OMBUDSMAN : Shri P.K. RATH

CASE OF MD. ISHAQUE V/S MAX LIFE INSURANCE COMPANY LTD


1. Name & Address of the Complainant Md. Ishaque Majid nagar, Ismail Chowk, PO : Islampur,

North Dinajpur, PIN : 733202 2. Policy No:

Policy Type/Duration/Period 503517716

DETAILS ARE IN THE TABLE 3. Name of the Insured/LA

Name of the proposer Shahnaz Begum (deceased)

Self 4. Name of the insurer Max Life Insurance Co. Ltd.

5. Date of Repudiation 16-09-2019 6. Reason for repudiation Misrepresentation / Suppression of material facts 7. Date of receipt of the Complaint 21-11-2019 8. Nature of complaint Dispute with regard to repudiation of death claim 9. Amount of Claim Rs 1,56,759/-


11. Amount of relief sought Rs 27,75,166/- 12. Complaint registered under

IOR’ 2017 13 (1) ( b )

13. Date of hearing/place On 07-02-2020 at SILIGURI 14. Representation at the hearing

For the Complainant Md. Ishaque

For the insurer Mr Jitendra Kr Garna & Dr Ashutosh Subhash Bhurke



Pol No L.A. PLAN DOC Premium

(yly)

Term /PPT

1ST Comp to Ins Co

503517716

Shahnaz Begum

Guaranteed Income Plan Non-linked Non-

participating

12-02-2018

1,56,759/-***

12/12 yrs

25-09-2019

***Renewal premium paid Date of death of the Life Assured (LA) : 01-05-2019

Policy duration : 1 year 2 months 19 days

Cause of repudiation of death claim : Suppression of material facts pertaining to pre-

existing diseases


lix) That he is the nominee under the above insurance policies which was purchased by his wife Mrs Shahnaz Begum who has expired on 01-05-2019.

lx) That thereafter, being the nominee, he has claimed the death benefit which has been repudiated by the insurer Max Life Insurance Company on the ground that the life assured was suffering from Lumbar Spondylosis with Multiple Degenerative Disc Disease and Ataxia prior to signing the proposal form and that the same was not declared at the time of purchasing the insurance policy.

lxi) That the disease was not at all there at the time of policy purchase and so declaration of the same is out of question.

lxii) That the policy was taken for natural / accidental death and that the cause of death mentioned in the discharge / death certificate is totally different from Lumbar Spondylosis with Multilevel Disc Disease and Ataxia. As such, treating the claim as declined based on non-declaration is not at all convincing.

lxiii) That it is requested to order the Max Life Insurance Company to pay the death claim amount.



Insurers’ argument: As per SCN received from the insurer – i) The deceased life assured (DLA) had stated in the relevant proposal form that she had never

been investigated / diagnosed or treated for any of the following – a. Disease of the Nervous System b. Any disorder of the Spine c. Any other medical condition

ii) However, investigations conducted after receipt of the death claim intimation from the nominee revealed that as per MRI report dated 24-02-2018 the life assured was diagnosed with “Lumbar Spondylosis with Multilevel degenerative disc disease.” Copy of the investigation report is attached with the SCN.

iii) As per Nerve Conduction Velocity (NCV) Study Report dated 24-02-2018 issued by Siliguri Neuro Center, the life assured was diagnosed with “Ataxia gait” i.e. abnormal & uncoordinated movement during walk. Copy of the NCV report is attached with SCN.

iv) On the basis of the above, the claim filed by the complainant was repudiated in accordance with Section 45 of the Insurance Act.




xii) Complaint letter ii) P – form iii) Proposal papers iv) SCN v) Discharge Summary issued by Siliguri Neuro Centre on 26-02-2018 vi) Hospital death certificate issued by Anandaloke Multispeciality Hospital, Siliguri vii) Attending physicians statement viii) MRI report dated 24-02-2018 issued by TENOVUS.


Both the parties were present and participated in the hearing.

The complainant submitted that at the time of policy purchase his deceased wife was not suffering

from any major disease and that the insurance company had conducted medical examination and had

issued the policy only after the same was found to be Ok. The complainant submitted that he is

headmaster of a school and has purchased several other policies from the same insurance company

during the period from 2014 to 2019. He added that incidents of his wife being detected with brain

tumor and being diagnosed to be suffering from cancer have all happened after the policy purchase.

The complainant further submitted that this is the reason for his non-acceptance of the premium

refund cheque sent by the insurance company.

The representatives of the insurance company submitted that medical documents reveal that as per

report dated 24-02-2018 the deceased life assured (DLA) was suffering from Lumbar Spondylosis with

Ataxia gait. They stated that the proposal paper was signed and submitted on 13-02-2018 but risk

was accepted on 28-02-2018. The insurer’s representative also submitted that as it is evident from

that discharge summary dated 26-02-2018 issued by Siliguri Neuro Center that the DLA was suffering

from diseases prior to acceptance of risk under the policy and as such the claim has been repudiated.

They further added that as one renewal premium had been received from the DLA the insurance

company has refunded the entire premium amount of Rs 3.10 lakhs to the complainant as per policy

terms and conditions.

AWARD


during the course of hearing and after going through the documents on record it is observed that

scrutiny of the proposal papers reveal that the Deceased Life assured (DLA) had answered all relevant

questions pertaining to her personal health and sufferings from diseases in the negative. The death

certificate issued by Anandaloke Multispeciality Hospital, Siliguri records that the immediate cause of

death is Ventricular Tachycardia and Glaucoma and Glioma, Hypertension, Type-2 DM and COPD are

the antecedent causes of death. The attending physicians statement issued by Dr Debojyoti Sarkar,

MD, DM (Cardiology) of Anandaloke Multi Specialty Hospital, Siliguri records that the DLA was a

Known Case Of (KCO) COPD, Hypertension and Diabetes Mellitus (DM) but there is no specific time

period mentioned.

The DLA was earlier admitted to Mitra’s Clinic & Nursing Home, Hakimpara, Siliguri from 23-03-2018

to 26-03-2018 and was diagnosed to be suffering from Multicentric Glioma, CNS Granuloma. The

relevant Hospital Discharge Summary records under the heading “History of Present Illness” that the

DLA was admitted with history of Ataxia. The insurer has submitted documents pertaining to MRI

report and NCV study report which pertain to the date 24-02-2018 which is just four days prior to

date of commencement of risk under the policy in this instant case. Thus, prima facie, it is obvious

that she must have been suffering from these diseases for a long duration which might have

preceded the date of proposal of the policy.

As such, it is established that the DLA was having prior knowledge of the diseases and has

intentionally suppressed the same with the malafide intent of purchasing the high value insurance

policy. Moreover in the premium receipt issued by the insurance company on 28-02-2018 it is

mentioned that - “Payment of premium amount does not constitute commencement of risk. The risk

commencement starts after acceptance of risk by us.” Thus it was imperative of the DLA to inform

the insurance company about detection of her illness, as evident from the MRI report and Siliguri

Neuro Center report, both dated 24-02-2018, as risk commencement under the policy was to start

from 28-02-2018. The DLA, by not providing this crucial information, has hindered the process of

actual assessment of risk by the insurance company.

In view of all the above, the repudiation of the claim made by the insurance company is upheld and

the insurer is directed to resend the premium refund cheque to the complainant.

Hence, the complaint is treated as disposed of without any other relief to the complainant.


P.K. RATH

INSURANCE OMBUDSMAN



(UNDER RULE NO: 16(1)/17 of THE INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN : Shri P.K. RATH

CASE OF RANJANA ROY V/S SBI LIFE INSURANCE COMPANY LTD COMPLAINT REF: NO: 1) KOL-L-041-1920-0189 AWARD NO: 1) IO/KOL/A/LI/ 0561 /2019-2020

1. Name & Address of the Complainant Mrs Ranjana Roy W/o Late Krishnapada Roy, Milpata, Dhupguri, Dist :

Jalpaiguri, PIN : 735210 2. Policy No:

Policy Type/Duration/Period 1K054446607

Details are in the table 3. Name of the Insured/LA

Name of the proposer Krishnapada Roy (Deceased)

Self

4. Name of the insurer SBI Life Insurance Company Ltd.

5. Date of Repudiation 21-09-2018 6. Reason for repudiation Suppression of material facts 7. Date of receipt of the Complaint 26-06-2019 8. Nature of complaint Dispute with regard to repudiation of death claim 9. Amount of Claim Rs 12,00,000/-



Insurance Ombudsman Rules’ 2017 13 (1) ( C )


For the Complainant Sangita Roy (Daughter)

For the insurer Chanchal kapani & Tamal Ray



Pol No L.A. PLAN DOC Premium (yly)

Term /PPT

1ST Comp to Ins Co

1K054446607 Krishnapada Roy

Convent-ional

14-06-2016 1,50,000 10/5 yrs 28-11-2018

Date of death of Life Assured : 27-11-2017 Basic Sum Assured : Rs 15,00,000 Date of repudiation : 21-09-2018 Date of representation to insurer : 28-11-2018 The complainant has alleged the following:- lxiv) That the above insurance policy was purchased by her deceased husband from the Dhupguri

Branch Office of SBI Life Insurance Co. That at the time of policy purchase the insurer had requested the deceased life assured (DLA) Krishnapada Roy, vide their letter dated 02-06-2016 to go for some medical tests at a particular institute whose name was mentioned in the said letter.

lxv) That the DLA accepted the request to go for the medical tests and after the completion of the tests and after getting the reports SBI Life issued the policy.

lxvi) That during the continuation of the policy the DLA died on 28-11-2017 at Military Hospital Binnaguri, PS Banarhat, Dist Jalpaiguri due to Congestive Cardiac failure in case of Myocardial Infarction shock and Asphyxia. Post Mortem was initiated at Jalpaiguri Sadar Hospital on 27-11-2017.

lxvii) That the complainant being legal heir to the deceased submitted Death Certificate issued by Binnaguri Cantonment Hospital to the insurance company on 11-06-2018. That after receipt of the claim intimation the insurance company carried out investigation and the complainant fully co-operated with the same.

lxviii) That thereafter the insurance company repudiated the claim on the ground that the policyholder was a patient of Diabetic Nephrology and had undergone treatment since 2013. The insurer paid premium amount of Rs 3 lakhs to the complainant.

lxix) That being aggrieved by this decision of the insurer the complainant made a representation before the Head, claims, SBI Life on 28-11-2018 but the Insurer intimated vide letter dated 18-02-2019 that the decision for repudiation of claim has been upheld.

As such, the complainant has now approached this forum for redressal of her grievance.

18) Cause of Complaint: Due to repudiation of claim on the ground of suppression of material facts.


Insurers’ argument: As per SCN received from the insurance company –

i) The life assured Krishna Pada Roy died on 27-11-2017. During the assessment of death it was found that the Deceased Life Assured (DLA) was suffering from Diabetes Mellitus Type 2, Diabetic Nephropathy prior to the date of signing of the proposal form and which was not disclosed by him in the proposal form.

ii) The claim was repudiated vide letter dated 21-09-2018 and an amount of Rs 3,00,000 was transferred to the complainant’s bank account towards refund of premiums.

iii) The company received a representation from the complainant and the case was referred to the Claims Review Committee (CRC) which was headed by a Retired Judge of Hon’ble High Court. The decision to repudiate the claim was upheld by the claims review committee as there was indisputable evidence on record to prove suppression of material facts by DLA at the time of proposal.

iv) Even if medical examination was conducted, it does not relieve the proposer from his duties of disclosure of material facts. If a person suffers from latent diseases like Diabetes Mellitus Type 2 and Diabetic Nephropathy, this will not get revealed at the time of preliminary medical examination.

v) The nature of medical examination depends on a host of factors including but not limited to sum assured and age of the life to be insured. The nature of medical examinations also depends on the information disclosed by the life to be insured in the proposal form for insurance.

vi) The DLA intentionally and fraudulently did not disclose the history of his treatment for Diabetes Mellitus and Diabetic Nephropathy in the proposal form and in the medical examination form and rather, replied in the negative to the specific questions regarding illness. If he had disclosed that he was suffering from the said diseases, the proposal would have been rejected by the Company.

vii) If the life insured reveals any adverse health history, the insurer will conduct the necessary probes relating to such adverse health condition. It is not prudent to subject every life to be insured to the rigors of extensive medical examination of the entire human system and there cannot be a single clinical test or a few tests which will prove to be sufficient to know everything about a human system.

viii) In the Medical Examination form, the deceased has replied in the negative to specific question no. 3 and 5 Thus during medical examination also, the DLA intentionally suppressed material facts and obtained insurance policy fraudulently.

ix) As per ECHS Polyclinic Bengdubi , the DLA Mr Krishna Pada Roy, having service no. 7238669, was taking treatment since 2011 onwards for Diabetes Mellitus Type 2, hypertension and Diabetic Nephropathy. It is clear from the medical records that the DLA was on Insulin. The said medical documents were submitted by the complainant herself. Copies of medical reports are submitted along with this SCN.

x) As per the Ex-servicemen Contributory Health Scheme ECHS Polyclinic Bengdubi C/o 158 Base Hospital Referral Form dated 28-07-2017 the DLA was advised for Haemodialysis opinion and splenectomy. The DLA was under Haemodialysis from January 2017 onwards. Copy of the same is also attached with this SCN.

xi) As per medical certificate of death, the antecedent cause of death is mentioned as Chronic Kidney Disease, type II DM, HTN. Copy of the Medical Certificate of Death is also submitted along with SCN.

xii) As such, it is submitted that the repudiation of claim by the Company for suppression of material facts and for the breach of Doctrine of Utmost Good faith is valid, just and legal. Hence all allegations in this regard are denied. The action of SBI Life insurance Company Ltd. is strictly as per the terms and conditions of the policy.

xiii) In light of the above, SBI Life Insurance Company Ltd prays that the Hon’ble Ombudsman may




xiii) Complaint letter ii) P – form iii) Proposal papers iv) SCN lxx) Post Mortem Report dated 27-11-2017 issued by Jalpaiguri Sadar Hospital lxxi) Police Final Report dated 26-12-2017 lxxii) Death Certificate issued by 164 military Hospital lxxiii) Prescriptions of different dates during the period from 01/2011 to 08/2017 issued by Military

Hospital / Ex-servicemen Polyclinic. lxxiv) Hemodialysis records of Paramount Hospital, Siliguri


The hearing was attended by both the parties. The complainant was represented by her authorised

representative and daughter Ms Sangita Roy whereas the insurer was represented by their two

officials named in 14 above.

The complainant’s representative submitted that her deceased father used to serve in a primary

school after retiring from army and that he did not suffer from any major disease. She added that at

the time of procuring the policy the insurer had conducted medical tests on her father and policy was

issued only after the tests were found Ok. The representative stated that the insurer has only

returned the premiums paid and it is not justified.

The representatives of the insurance company repeated what has been already stated in their Self

Contained Note (SCN) submitted to this office. They further stressed on the fact that a contract of

insurance is based on the principle of utmost good faith and that the same has been violated by the

deceased life assured (DLA) by answering all health related questions in the proposal form in the

negative.

AWARD


during the course of hearing and after going through the documents on record it is observed that the

Deceased Life Assured (DLA) was an ex-serviceman aged 56 years. Scrutiny of the large number of

copies of prescriptions issued by the Doctors at Hospital / Polyclinic / OPD facility at Military Hospital

clearly establishes the fact that the Deceased Life Assured (DLA) had been suffering from Type 2 DM,

HTN and Diabetic Nephropathy since 04-01-2011 and had been undergoing treatments and

medications for the same for a period of 6 six years from 2011 to 2017. This aspect confirms the fact

that the DLA was having knowledge of his suffering from Diabetes at the time of purchasing the

policy. But he has not mentioned about the same in the relevant proposal form. That the insurer had

conducted his medical examination and had approved his policy thereafter cannot have a bearing on

the basic fact that the DLA had directly denied suffering from Diabetes and had suppressed

information about a such a serious disease although he was undergoing treatment for the same over

the past several years.

Perusal of the relevant prescriptions and medical documents show that the DLA was also undergoing

treatments for several other diseases such as Chronic Kidney Disease (CKD), Hypertension (HTN) and

Anemia for the past several years prior to policy purchase. These facts were also not mentioned by

the DLA in the relevant proposal form. The Hemodialysis records of Paramount Hospital show that

the DLA underwent regular Hemodialysis at Paramount Hospital during the period from 02/2017 to

04/2017 which obviously is a consequence of the severe long standing diseases with which the

policyholder was afflicted over a period of several years, prior to the purchase of the policy. The

death certificate issued by 164 Military Hospital clearly records that the antecedent cause of death is

Chronic Kidney disease, Type-II DM, HTN and Anemia.

In view of all the above the malafide intent of the deceased life assured is quite evident and as such

the decision of repudiation of claim made by the insurance company on the ground of suppression of

material facts is justified. The insurance company has intimated that they have already refunded the

premium amount of Rs3 lakhs to the nominee cum complainant directly into her bank account

through NEFT and the same has been also acknowledged by the complainant in her complaint letter

submitted to this forum. Hence the case is dismissed without any relief to the complainant.



P.K. RATH

INSURANCE OMBUDSMAN



(UNDER RULE NO: 16(1)/17 of THE INSURANCE OMBUDSMAN RULES, 2017) OMBUDSMAN : Shri P.K. RATH

CASE OF PRITI DEY GHOSH V/S STAR UNION DAI-ICHI LIFE INSUARNCE CO.


1. Name & Address of the Complainant Mrs Prity Dey Ghosh W/o Bappa Ghosh, Panishalahat, Dhowabushua, PO :

Panishalahat, PS : Raiganj, North Dinajpur, PIN : 733134




Mrs Priti Dey Ghosh Self

4. Name of the insurer Star Union Dai-Ichi Life Insurance Co.

5. Date of Repudiation Not Applicable 6. Reason for repudiation Not Applicable 7. Date of receipt of the Complaint 17-01-2019 8. Nature of complaint Dispute with regard to partial or total repudiation of

claim. 9. Amount of Claim Could not be ascertained



Insurance Ombudsman Rules’ 2017 13 (1) ( B )


For the Complainant Mrs Prity Dey Ghosh & Mr Bappa Ghosh (Husband)

For the insurer ABSENT



Pol No L.A. PLAN DOC Premium (yly)

Term /PPT

1ST Comp to Ins Co

01076694 Priti Dey Ghosh Non-linked Non-participating HI

25-03-2017 Rs 9120 10/10 yrs 30-10-2018

The complainant has alleged the following:- lxxv) That her husband is a consumer of Union Bank of India, Raiganj Branch and he is having

cash/credit account with that bank branch. Hat in March’ 2017 when she and her husband had visited the branch for their personal work, they were persuaded by the branch manager and one representative of Star Union Dai-ichi Life Insurance Company Limited to purchase the aforementioned health insurance policy with the assurance that it was the best available policy and that there would not be any inconvenience for getting the claim (if required).

lxxvi) That she had mentioned at the time of purchasing the policy that 12 years ago when she had conceived for the first time, serious gynaecological problems resulting in the baby getting aborted and she had to undergo Kidney Dialysis.

lxxvii) That due to this disclosure before paper works she had to appear before a medical practitioner as appointed by the insurance company and only then the policy was issued to her. That she had disclosed everything before the insurance company’s medical practitioner also. That after some days she was called at the bank and the official obtained her signatures on the policy agreement papers which were filled up by the representative of the insurance company and then after some time she received the new policy certificate bearing number 01076694 for Health Insurance having sum of Rs 5,00,000/-

lxxviii) That thereafter after completion of Kidney Dialysis she was completely cured and subsequently on baby girl was born to her whose at the time of policy purchase was 8 years.

lxxix) That in the year 2018 she was diagnosed with breast cancer and underwent treatment for the same at Tata Memorial Hospital (TMC), Mumbai. There she first underwent Chemotherapy and then surgery and then again chemotherapy. Thereafter the doctor has advised her to undergo 17 cycles of chemotherapy upto 22-06-2019.

lxxx) That during the course of treatment she has expended more than Rs 5 lakhs but when she submitted her claim to the insurer Star Union dai-ichi along with all documents, the insurer has repudiated the claim vide their letter dated 29-10-2018 because of her previous treatments of Dialysis.

lxxxi) That she had disclosed her previous treatment history at the time of policy purchase and the insurer has issued the policy only after being fully satisfied and after conduct of medical examinations. That she has also written to the Claims Review Committee of the insurance company on 12-12-2018 but no satisfactory response has been provided.

As such, aggrieved by the repudiation of claim, the complainant has now approached this forum for




Insurers’ argument: As per SCN received from the insurer – i) Policy has been issued only after receipt of duly filled up application form and relevant

declaration regarding full understanding of policy terms and conditions along with valid documents submitted by the complainant cum policyholder. The policy bond has been already received by the complainant.

ii) The complainant has submitted the Critical illness Claim Form on 11-06-2018 and a pr the contents of the same the complainant had symptoms of “Tumor in Right Breast” since 20-03-2018. As the relevant treatment documents were not accompanying the claim form the same were called for vide letter dated 12-06-2018 wherein Indoor case papers, Consultation papers and Medical reports, etc. were asked to be submitted.

iii) As per treatment documents received the complainant was admitted at Sunrise Nursing Home Pvt. Ltd. Siliguri on 22-09-2018 and relevant treatment papers mention that the complainant had H/o Hypertension since age 34 and H/o Dialysis in post partum period at age 23 years. These material facts were not disclosed by the complainant in the proposal form.

iv) The treatment papers of Tata Memorial Hospital also mentions clearly under the head – Clinical Information – that the complainant had H/o hypertension diagnosed at 34 yrs, discontinued Rx, now on Amlong 5mg*2. As per information available in public domain Amlong 5 mg tablet is used to treat high blood pressure and other heart complications.

v) Hence it is clearly understood from the treatment documents that the complainant was suffering from Hypertension prior to issuance of the policy and had intentionally suppressed the material information to take insurance coverage from the company. Further the treatment papers of TMC also states – “F/h/o – father-Brain ca – 60 y”. It shows that the complainant had family history of Cancer which was suppressed by the complainant.

vi) The complainant had also concealed facts regarding abortion of her child and her breast operation in the proposal form and answered the relevant questions in the negative.

vii) Based on the above findings it was concluded that the complainant had intentionally suppressed / mis-represented multiple information in the proposal form and as such the claim was repudiated and in accordance to Section 45 of the Insurance Act, the policy was cancelled and the premium amount of Rs 18,108/- was transferred to the complainant’s bank account.

viii) The complainant has stated in the proposal form that she is a XII pass and it is a hard truth to believe that she was not aware of the contents of the Proposal Form and had signed it blindly without verification.




xiv) Complaint letter ii) P – form iii) Proposal papers iv) SCN v) Case summary issued by Sunrise Nursing Home Pvt. Ltd., Siliguri

vi) Case letter dated 01/10/2018 issued by Tata Memorial Hospital, Mumbai.

lxxxii) Communication dated 29-01-2020 of the insurer containing copy of the DCDRF Notice in respect of Consumer Case No. CC – 64/2019.


The complainant was present in the hearing along with her husband. The insurer was not represented

as they had sent a prior communication dated 29-01-2020 wherein they had submitted that they be

excused from being present at the hearing as the complainant had already filed a case against the

Company before District Consumer Disputes Redressal Forum (DCDRF), Uttar Dinajpur, Raiganj and

the same was already listed for hearing at that Forum on 06-02-2020. The insurer had also sent a

copy of the notice received by their Company from DCDRF, Raiganj. The competent authority had

granted their request.

During the course of hearing the complainant and her husband repeated the allegations as

mentioned in the written. They submitted that they have already filed a complaint before the DCDRF,

Raiganj.

AWARD

Taking into account the fact that the complainant has already filed a complaint with District

Consumer Dispute Redressal Forum, Uttar Dinajpur, Raiganj vide Consumer Case Number CC –

64/2019, the complaint in this instant case is not maintainable before the Insurance Ombudsman as

per Section 14 (5) of Insurance Ombudsman Rules’ 2017.

Hence, the complaint is treated as dismissed without any relief to the complainant.

Dated at KOLKATA on 13th day of February’ 2020.

P.K. RATH

INSURANCE OMBUDSMAN


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PROCEEDINGS BEFORE - THE INSURANCE OMBUDSMAN, LUCKNOW


Mrs. Aneeta Mishra ………….……..……....……………………………………. Complainant

V/S

Life Ins. Corp. of India ………………..…………………….……………………………Respondent

COMPLAINT NO: LCK-L-029-1819-0462 Order No. IO/LCK/A/LI/ 0357 /2019-20

1. Name & Address of the Complainant Mrs. Aneeta Mishra

w/o Late Sri Aditya Nath Mishra

Gomti Nagar

Lucknow

2. Policy No:

Type of Policy

Duration of policy/DOC/Revival

275017672 and 275017673

MONEY BACK, Jeevan Chhaya

28.06.2011 in both policies

3. Name of the life insured


Late Sri Ved Prakash Jaiswal


4. Name of the insurer Life Ins. Corp of India

5. Date of Repudiation/Rejection -

6. Reason for repudiation/Rejection -


8. Nature of complaint DAB not paid

9. Amount of Claim S.A. Rs.75,000/=, Rs.75,000/=

10. Date of Partial Settlement ---

11. Amount of relief sought ---

12. Complaint registered under Rule Rule No. 13(1)(b) of Ins. Ombudsman Rule

2017

13. Date of hearing/place On 14.02.2020 at 10.15 am at Lucknow


a) For the Complainant Mrs. Aneeta Mishra

b) For the insurer Shri Heera Singh

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17. Mrs. Aneeta Mishra (Complainant) has filed a complaint against Life Ins. Corp. of India

(Respondent) alleging non-payment of DAB claim of her husband.

MS

COMPLAINT NO: LCK-L-029-1819-0462 Order No. IO/LCK/A/LI/ 0357/2019-20

Brief Facts of the Case: -

18. Mrs. Aneeta Mishra has filed a complaint on12.12.2018 before this forum alleging that the

Death Accidental Benefit Claim of his husband`s policies was not paid by the insurance

company. As per complainant the policies were issued on the life of her husband Late Aditya

Nath Mishra, who died on 09.08.2016 in Icon Hospital Lucknow. In his death claim intimation

and other claim papers dated 02.05.2018 the complainant has stated that death was due to

injuries falling from roof. She has submitted death claim papers as required by the company

and the company settled the death claim for basic sum assured but DAB was not paid by the

company. She approached the company for DAB payment on 07.09.2018 stating cause of

death was an accident but nothing was heard from them. Being aggrieved, the complainant

approached this forum for payment of DAB claim which was not paid and redressal of her

grievance. The complainant has enclosed News Paper cutting with the complaint letter.

Written reply/SCN:-

19. In their SCN/reply, the respondent has stated that the Corporation was in receipt of a death

claim under the policies along with claim forms and relevant documents. In death claim paper

cause of death was mentioned as injuries due to falling from roof. The death claim was admitted

for basic sum assured and payment sent in to nominees‟ bank account accordingly on

04.05.2018. Regarding DAB claim, required document as FIR, Pachnama, PMR, Final report

was not submitted by the claimant. The Corporation received a legal notice from claimant

demanding DAB claim in which she mentioned death due to road accident. On receipt of

clarification regarding cause of death and other claim paper required for DAB, claim may be

decided.

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20. The complainant has filed a complaint letter, annexure VI A and correspondence with

respondent while respondent has filed SCN to consider this case as closed/resolved in favour of

RIC.

21. I have heard the complainant as well as respondent representative and perused the record.


Findings:-

22. Undisputedly insured namely Aditya Nath Mishra had taken 2 policies from the LIC. He died

on 09.08.2016. Death claim was paid to his nominee but the accidental benefits were not paid.

Subsequently complainant moved this forum.

23. At the very outset I would like to observe the negligence of the part of Officers of Divisional

Office, Faizabad. Inspite of specific direction the Concerned Manager (Claims) Divisional Office

LIC, Faizabad is opting a very callous, negligent attitude in performing of his duties. A very

sketchy SCN was submitted wherein no details are mentioned as to when the accident claim

was submitted by the complainant when necessary record were asked from the complainant.

Even the letters sent to the complainant have not been annexed. It needs an immediate

attention of the Senior Officers of the LIC for taking appropriate action.

24. As per the SCN this case of payment of accidental benefit is still pending due to non receipt

of documents. I have gone through the record and found that the complainant herself has made

2 contradictory statements regarding cause of accident. In the application to Branch Manager

LIC, Faizabad he has stated that the insured deceased sustained injuries due to falling from the

roof while in the notice dated 07.09.2018 it is stated that insured deceased sustained injuries

due to an accident wherein some unknown vehicle hit the insured. However since the matter is

still pending at the level of the LIC for such a long time it would be appropriate that the

respondent LIC should dispose off the matter within the period of 30 days.

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Order:-

25. Complaint is allowed to the extent that the respondent LIC of India should dispose off the

accident claim matter of insured deceased within a period of 30 days positively.

26. Let a copy of this order be sent to the Zonal Manager LIC, Kanpur as well as Senior

Divisional Manager LIC, Faizabad Division, Faizabad for necessary action.


27. Let the copy of award be given to both the parties.

Date: 14.02.2020 (Justice Anil Kumar Srivastava)

Place: Lucknow Insurance Ombudsman



Mrs. Asha Devi……………….……..……....……………………………………. Complainant

V/S

Life Ins. Corp. of India ………………..……………………………………………Respondent


1. Name & Address of the Complainant Mrs. Asha Devi

Noorwas, Tikaitnagar,

Distt. Barabanki

2. Policy No:

Type of Policy


275210932

Jeevan Saral

28.09.2011

Pag

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Late Sri Shiv Sharan Maurya



5. Date of Repudiation/Rejection 16.04.2018

6. Reason for repudiation/Rejection Not opted



9. Amount of Claim S.A. Rs.3,12,500/=




2017



a) For the Complainant Mrs. Asha Devi

b) For the insurer Mr. Heera Singh



17. Mrs. Asha Devi (Complainant) has filed a complaint against Life Ins. Corp. of India


MS



18. Mrs. Asha Devi has filed a complaint on 22.02.2019 before this forum alleging that the DAB

claim of his husband`s policy was not paid by the insurance company. As per complainant the

said policy was issued on the life of her husband Late Shiv Sharan Mourya who died on

05.01.2015 in a road accident in Saudi Arabia. The complainant has stated that she has

submitted all DAB claim paper and DAB amount was paid in her account on 04.08.2017 but

Pag

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suddenly withdrawn on 15.12.2017 by LIC. She approached the RIC for DAB payment but they

rejected her claim stating that deceased life assured had not opted/ applied for DAB and

premium charged for DAB was refunded by them. Being aggrieved, the complainant

approached this forum for payment of DAB claim and redressal of her grievance.

Written reply/SCN:-

19. In their SCN/reply, the respondent has stated that the Corporation was in receipt of DAB

claim under the policy along with relevant documents. The respondent has stated that in

proposal form DLA mentioned “Not Required” in the column of DAB so premium of DAB was

refunded to the claimant as decided by divisional standing committee and the claimant was

informed accordingly.

20. The complainant has filed a complaint letter, Ann VIA and correspondence with respondent

while respondent has filed SCN to consider this case as closed/resolved in favour of RIC.


Findings:-

22. It is typical case wherein the deceased life assured was Shiv Sharan Maurya who had taken

the insurance policy with sum assured of Rs. 312500/-. He died on 05.01.2015 in road accident.

The claim benefits along with accident claim benefits were paid by the respondents but before it

could be withdrawn by the nominee accident claim benefits were withheld and withdrawn by the

respondent on the ground that in the proposal form it is mentioned that the insured did not want

to take accident claim benefit. Feeling aggrieved complainant moved to this forum.


23. It is admitted that in response to proposal form policy bond was issued by the respondent

wherein Rs. 312.50 were deducted as premium for accident benefit. This premium was

continuously received by the respondents from the date of commencement of the policy till the

date of death of the life assured. Now the question to be looked into is as to whether it can be

accepted that the life assured was not covered under accident benefit assurance?

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e7

24. Admittedly in the proposal form accident benefit were not taken by the insured and the

relevant column it is mentioned that “NR”. Policy bond was prepared and issued wherein

amount of Rs. 312.50 was being received by the respondent as premium for accident benefits.

When the proposal form was submitted and premium for accident claim are claimed and

received by the insurance company it means that a counter proposal was given by the

respondent insurance company to the life assured which in turn was accepted by the

complainant by way of making the payment of annual premium continuously. Hence a valid

contract was entered between the insurers and insured. This valid contract was with regard to

accident benefits. When a valid contract exists between insurer and insured now the insurer

cannot deny its liability. Insurer has to honour the contract as well as its own policy bond.

Insurer has also deposited the amount accident claim benefit in the complainant‟s account

which was subsequently withheld and withdrawn by the insurer. In the circumstances I am of the

view that the complainant is entitled for the accident benefit for the death of her husband life

assured subject to rules and terms and conditions of the policy bond.

Order:-

25. Complainant is allowed. Complainant is entitled for accident benefit claim of life assured.

Respondent shall make the payment from the date of making the claim till the date of actual

payment with the interest of 8 percent per annum within 30 days.




Pag

e8



Ms. Garima Sawhney…………..….……………………….……….……..…. Complainant

V/S

HDFC Life Insurance Co. Ltd……………………………………………………Respondent

COMPLAINT NO: LCK-L-019-1819-0337 Order No. IO/LCK/A/LI/0310/2019-20

1. Name & Address of the Complainant Ms. Garima Sawhney

Ansals Ashiyana

Lucknow

2. Policy No:

Type of Policy


90515847

Cancer Care

13.06.2017



Mr. Deepak Sawhney

Mr. Deepak Sawhney

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


6. Reason for repudiation/Rejection Claim under waiting period



9. Amount of Claim S.A. Rs.1000000 /=




2017



a) For the Complainant Ms. Garima Sawhney

b) For the insurer Mr. Sudhir Kumar Singh



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e9

17. Ms. Garima Sawhney (Complainant) has filed a complaint against HDFC Life Ins. Co. Ltd.

(Respondent) alleging wrong repudiation of death claim.

MS


Brief facts of the case:-

18. The complainant has stated that her father had taken one policy no.90515847 on his life

from HDFC Life. Unfortunately he expired on 04.01.2018. Being nominee in the policy she

submitted claim form to RIC but death claim under policy was rejected by the RIC on the ground

that “Waiting period of 180 days will apply from the date of commencement of cover. The policy

shall terminate and no benefit shall be payable under the policy”. The claimant also approached

GRO but nothing was done by them. She wants to know the basis of waiting period from

RIC/GRO but not satisfied. Being aggrieved, the complainant approached this forum for the

redressal of her grievance.

Written reply/SCN:-

19. In their SCN/reply, RIC has stated that the policy was issued on the basis of duly signed

proposal form. The deceased life assured was an educated person and he was aware with the

terms and conditions of the policy. On dated 11.06.2018 the company received duly signed

statement of death claim confirming the death of life assured on 04.01.2018. Death claim was

rejected by the company. The claim was rejected on the ground of terms and conditions of the

policy in question. The complainant also intimated via e-mail dated 08.08.2018 and 20.08.2018

and as per the Histopathology report dated 28.07.2017 that patient had squamous cell

Carcinoms of tongue which fall within 180 days waiting period conditions from the policy

inception date which is 13.06.2017.


respondent while respondent has filed SCN with enclosures.


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Findings:-

22. Policy was taken by the insured deceased at the age of 65 years on 13.06.2017. He died on

04.01.2018. Cause of death was Squamous Cell Carcinoma. Claim was repudiated on the


ground that the waiting period of 180 days would apply from the date of commencement of

cover. Deceased was diagnosed within the waiting period of 180 days.

23. Complainant submit that the deceased insured was a vigilant person who was quite hale

and hearty at the time of taking of the policy. He was not suffering from any disease. It is further

submitted that carcinoma of any type is a disease which can occur at any point of time. It is

further, submitted that the insured deceased had no intention to deceive the respondent.

24. According to histopathology report dated 28.07.2017 insured deceased had Squamous Cell

Carcinoma of tongue which falls within 180 days waiting period condition from the policy dated

that is 13.06.2017. Subsequently he was under treatment at SGPGI, Lucknow for the same

disease. Insured deceased expired due to the said disease.

25. Repudiation is made by the respondent on the basis of terms and conditions of the policy

bond. Insured as well as insurer are bound by the terms and conditions of the bond. They can

not deviate from the same. This fact is not disputed that the deceased was diagnosed within a

waiting period of 180 days. Accordingly respondents have rightly repudiated the claim which

does not require any interference. Accordingly complaint is liable to be dismissed.

Order:-

26. Complaint is dismissed.


Date: 03.02.2020 Justice Anil Kumar Srivastava


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Smt. Mala Sharma……………………..………..……....…………………. Complainant

V/S

HDFC Life Insurance Co. Ltd……………………………………....…………………Respondent


1. Name & Address of the Complainant Smt Mala Sharma

w/o Lare Sri Ram Babu Sharma

Nainagarh, Nagra

Distt. Jhansi

2. Policy No:

Type of Policy


PP000092

HDFC Life Group Credit Protect PLUS

11.04.2017



Late Sri Ram Babu Sharma

HDFC Limited



6. Reason for repudiation/Rejection Suppression of material facts regarding

health



9. Amount of Claim ---




2017



a) For the Complainant Smt. Mala Sharma




17. Smt. Mala Sharma (Complainant) has filed a complaint against HDFC Life Ins. Co. Ltd.


Pag

e12

MS

COMPLAINT NO: LCK-L-019-1819-0445 Order No. IO/LCK/A/LI/ /2019-20


18. As per complainant, the said policy was issued on the life of her husband Late Sri Ram

Babu Sharma for Sum Assured of Rs. 10,21,784/- on 11.04.2017 who died on 03.12.2017. RIC

had repudiated the death claim stating that DLA had given false statement regarding his health

at the time of proposal. The complainant has stated that in 2017 her husband applied for home

loan and loan was approved. In the meanwhile representative of the company approached her

husband for insurance and her husband denied for the same due to his disable condition and

illness of diabetes, he had submitted his handicapped certificate at proposal stage and also told

the facts about his health. Proposal form was filled by agent and her husband only signed the

proposal. Name of her husband was also not correct on policy bond. In view of complainant, her

husband had not made any false statement regarding his health. The complainant has also

given her statement before investigator of company regarding diabetes of her deceased

husband. After repudiation of her husband`s death claim, she approached Review Committee

of RIC but they uphold the decision of company. Being aggrieved with the decision of RIC, she

has approached this forum for payment of death claim for redressal of her grievance.

Written reply/SCN:-

19. In their SCN/reply, RIC has stated that the claim was repudiated as DLA had made false

statement regarding his health at the time of proposal. The RIC has stated that Insurance

contact are based on the principle of utmost good faith and the policies are issued based on the

information‟s given in the proposal form and any disclosure in the form renders the contract

voidable at the option of the insurer. It is, therefore, evident that DLA had made deliberate mis-

statements and with-held material information with us regarding his health at the time of signing

of proposal form that he was the patient of diabetes and hypertension and taking medicine at

proposal stage. Since DLA had suppressed material facts, knowingly, so claim was repudiated

on17.05.2018. Review Committee of the RIC had also upheld their decision on 06.07.2018.

Pag

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Findings:-

22. Insurance policy was taken by the insured as a collateral policy for the loan taken from

HDFC Bank. Policy was taken on 11.04.2017 while insured died on 03.12.2017. It is neither

disputed nor can be disputed that the insured was a physically handicapped person with 85

percent disability which was certified by the Chief Medical Officer, Jhansi on 07.02.2001.

23. Claim of the complainant was repudiated by the respondents on the ground of concealment

of material facts. In the proposal form in column no. 1 wherein it is asked as to whether insured

has any kind of physical disability the reply is marked as no. This is patently wrong. Insured was

having the physical disability as he was not having one leg. Such disability can be viewed by

naked eye but wrong information was provided by the insured that too in connivance with the

agent. Agent is the person who meets the insured and gets the proposal form filled in. It is

excepted from the agent that correct particulars are filled in the proposal form. Physical disability

is a fact which should have been observed by the agent namely Neha Sahani but it appears that

intentionally in order to deceive the Insurance Company she colluded with the insured.

Accordingly in the proposal form no physical deformity of the insured was shown. Such type of

conduct of agent has to be depreciated. Strong administrative action should be taken against

the agent by the Insurance Company.

24. Another ground of repudiation is that the insured was suffering from diabetes but these facts

are not disclosed in the proposal form. Prescriptions of insured dated 09.09.2015 show that in

pathological report fasting blood sugar was 373 and PP 400. Even in the complaint itself it is

admitted that the insured was having diabetes but for some time. In the report dated 04.07.2016

fasting blood sugar shown as 179 and PP is 270. Such reports collaborates the repudiation.

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e14

25. In such circumstances I am of the view that the respondents have rightly repudiated the

claim. Complaint deserves to dismissed.


Order:-

26. Complaint is dismissed. It is recommended that Insurance Company shall take a strict action

against the agent namely Neha Sahani.

27. Let a copy of award be given to both the parties.





Smt. Sapna Umar………………………….…..……....…………………. Complainant

V/S

HDFC Life Insurance Co. Ltd………………………………………..………………Respondent


1. Name & Address of the Complainant Smt. Sapna Umar

Purani Bajaji

Mirzapur

2. Policy No:

Type of Policy


18943478

Sampoorn Samridhi Plus

16.01.2017



Late Sri Baccha Lal

Late Sri Baccha Lal




income

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9. Amount of Claim S.A. Rs. 221801/=

10. Date of Partial Settlement Premium amount of Rs.13225/- refunded



2017



a) For the Complainant Smt. Sapna Umar




17. Smt. Sapna Uamar (Complainant) has filed a complaint against HDFC Life Ins. Co. Ltd.


MS



18. As per complainant, the said policy was issued on the life of her father Late Sri Baccha Lal

for Sum Assured of Rs. 221801/- on 16.01.2017 who died on 21.01.2017. RIC had repudiated

the death claim stating that DLA had given false statement regarding his occupation and income

at the time of proposal. In view of complainant, her father had not made any false statement

regarding his occupation and income. She has submitted ITR for the year 2014-15 and 2015-16,

TIN certificate in support of income proof. She visited many times to RIC`s office for payment of

death claim but they always asked for income proof which was already submitted. After

repudiation of his father`s death claim, he approached GRO of RIC but nothing was heard from

them. Being aggrieved with the decision of RIC, he has approached this forum for payment of

death claim and for redressal of her grievance.

Pag

e16

Written reply/SCN:-

19. In their SCN/reply, RIC has stated that the policy was issued on the basis of duly signed

proposal form. On dated 22.03.2017 the company received duly signed statement of death

claim confirming the death of life assured on 21.01.2017. Death claim was repudiated by the

company. The claim was repudiated on the ground of non-discloser of income/occupation at the

time of inception of policy. Upon receiving the death claim the company appointed an

investigator to investigate the matter. As per statement of shop owner it is clearly mentioned

that DLA was working in his shop, and was earning Rs.3000/ per month. He has stopped to

come in his shop before two month from his death. It was also confirmed by the nominee in her

statement that the DLA was working at cloth store. The RIC has also stated that in investigation

report it is submitted that the policy was purchased with malafied intention by declaring the false

facts of DLA income and financial status, as the family is very poor and cannot afford to buy any

insurance policy. Under the said policy hly premium was refunded by the company. On hearing

dated 03.02.2020 the complainant was not present.

20. The complainant has filed a complaint letter, Ann VI A and correspondence with respondent

while respondent has filed SCN with enclosures.



Findings:-

22. Undisputedly deceased life insured Baccha Lal took the policy on 16.01.2017. He died on

21.01.2017 that is after 5 days. Death claim was submitted by the complainant that is nominee

which was repudiated on the ground that age occupation and income details in the application

dated 16.01.2017 were mis- representated. Accordingly claim was repudiated and premium paid

Rs. 13225/- was refunded which is under challenge. In the proposal form DLA has shown his

occupation as self employed/business. Gross annual income of the insured was Rs. 1,95,000/-

from business at purani bajaji, Mirzapur. Repudiation was made on the basis of investigator‟s

report. It is relevant that the cause of death is not disputed.

Pag

e17

23. One Ritesh Kesharwani stated that Baccha Lal was working in his shop and was getting Rs.

3000/- per month as salary. Complainant has attached the ITR of DLA wherein the assessment

year 2014-15 submitted on 15.03.2016 annual income is shown as Rs. 215890/-. An amount of

Rs. 22267/- was deducted as tax which was refunded. In the assessment year 2015-16 annual

income was shown as Rs. 265410/- tax of Rs. 32777/- was paid which was also refunded.

Coupled with it DLA has taken an agency of recharge voucher, SIM under the name of M/s

Yashi Enterprises with a TIN No. 09814807351S. In the SCN there is neither any denial nor any

explanation regarding income tax return submitted by the DLA. Income tax retuns were filed on

15.03.2016 much prior to the death or commencement of the policy. Except for the statement of

the shop owner and the nominee there is no material to show that the DLA was not earning the

amount as shown in the ITRs. Claim was repudiated on the ground of mis-statement regarding

income and occupation which could not be substantiated by the respondent insurance

company. There is no reason to dis-believe the ITRs of DLA as well as certificate of registration

and allotment of TIN issued by the Competent Authority of the Commercial Tax Department,

Mirizapur.


24. On the basis of discussion made above I am of the view that the respondent has wrongly

repudiated the death claim of the DLA. Complainant/Nominee is entitled to the death claim of

DLA Baccha Lal. Accordingly complainant is allowed.

Order:-

25. Complaint is allowed. Respondent are directed to make the payment of death claim to the

complainant nominee within a period of 30 days. Amount, if any, already paid shall be adjusted.




Pag

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Mrs. Laxmi Srivas ………………………………………………………………Complainant

V/S

India First Life Insurance Co. Ltd………..…...……………..………………...Respondent

COMPLAINT NO: LCK-L-024-1920-0375 ORDER NO. IO/LCK/A/LI/ 0412/2019-20

1.

Name & Address of the Complainant Mrs. Laxmi Srivas

Vill. & Post Sultanpur

Distt. Pratapgarh

2. Policy No:

Type of Policy

Duration of policy/DOC

G0000611

Pradhan Mantri Jeevan Jyoti Bima Yojna

26.05.2017



Late Doodh Nath Srivas

Late Doodh Nath Srivas

4. Name of the insurer India First Life Insurance Co. Ltd.


6. Reason for repudiation/Rejection Beyond free-look



9. Amount of Claim Rs.2,00,000/=



12. Complaint registered under Rule Rule No. 13(1)(b) of Ins. Ombudsman Rule 2017

13. Date of hearing/place On 26.02.2020, 10.30 AM at Lucknow


a) For the Complainant Mrs. Laxmi Srivas

b) For the insurer Mr. Vikash Gupta

15. Complaint how disposed Recommendation


17. Mrs. Laxmi Srivas (Complainant) has filed a complaint against India First Life Ins. Co. Ltd.

(Respondent) alleging wrong repudiation of her husband‟s death claim.

Pag

e19

COMPLAINT NO: LCK-L-024-1920-0375 ORDER NO. IO/LCK/A/LI/ /2019-20

Brief Facts of the Case:-

18. Mrs. Laxmi Srivas has filed a complaint on 11.09.2019 before this Forum alleging that the

death claim of her husband late Doodh Nath was wrongly repudiated by India First Life

Insurance Co. Ltd. The complainant has stated that her husband died due to sudden heart

failure at Nagpur (Maharastra). He was a barber there. She has submitted death claim through

bank with death certificate issued by Pratapgarh authorities. She was not received claim

amount. On enquiry they have asked for online death certificate so she tried to produce death

certificate from Nagpur, but death claim was repudiated by the RIC stating death certificate was

fake. Being aggrieved, the complainant approached this forum for the redressal of her

grievance.

Written reply/SCN:-

19. In their SCN/reply, the company has stated that DLA had applied for a policy under Pradhan

Mantri Jeevan Jyoti Bima Yojna. Policy was issued vide master policy no.G0000616 under

account bearing no.22938100006013 with annual premium Rs.330 and sum assured

Rs.2,00,000/-. The company had received death claim intimation form with death certificate and

some other document from nominee Mrs. Laxmi intimating that DLA had died on 22.08.2017.

The company had conducted investigation, it was revealed that the death certificate submitted

was fake and stands cancelled by the authority. There is deliberately attempt to defraud the

company by submitting forged and fabricated claim. The company had rejected the claim on the

ground of submission of fake death certificate and conveyed to the complainant vide letter dated

12.12.2017.

20. The complainant has filed a complaint letter, Annexure VI A and correspondence with


RIC.


Pag

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COMPLAINT NO: LCK-L-024-1920-0375 ORDER NO. IO/LCK/A/LI/ 0412/2019-20

Findings:-

22. Death claim was repudiated on the ground that the death certificate of deceased Doodh

Nath Srivas found to be fake. He died at Nagpur but the death was registered at Pratagarh that

too manually. It was reported that in the year 2017 death was registered online. There was no

procedure for issuing manual certificate.

23. Today complainant has submitted a death certificate issued by Government of Maharashtra,

Municipality Kamptee dated 26.10.2017. Complainant submits that since the deceased died at

Nagpur, hence the same was registered online at Nagpur on 26.10.2017. A copy of the same is

provided to the respondent representative.

24. Since online registered death certificate is provided to the respondent today it would be

appropriate that the claim should be reviewed and decided by the respondent.

Order:-

25. Complainant is disposed off with a direction to the respondent to review the claim within 30

days in view of the death certificate provided today to the respondent representative. If the

complainant is not satisfied with the decision of the respondent she would be at liberty to

proceed in accordance with law.



Place: Lucknow (Insurance Ombudsman)

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Sri Tribhuwan Prasad…………………..……..……....…………………. Complainant

V/S

Life Insurance Corp. of India …………………………………………………Respondent


1. Name & Address of the Complainant Sri Tribhuwan Prasad

Husband of Late Munni Devi

Sonikpur, Barabanki

2. Policy No:

Type of Policy


276292836

-

20.04.2015



Late Munni Devi

Late Munni Devi

4. Name of the insurer Life Insurance Corp. of India


6. Reason for repudiation/Rejection Suppression of material facts regarding age



9. Amount of Claim S.A Rs. 1,00,000/-




2017



a) For the Complainant Sri Tribhuwan Prasad




Pag

e22

17. Sri Tribhuwan Prasad (Complainant) has filed a complaint against Life Ins. Corp. of India


MS



18. As per complainant, the policy was issued on the life of his wife Late Munni Devi for Sum

Assured of Rs. 100000/- on 20.04.2015 who died on 09.09.2017. RIC had repudiated the death

claim stating that DLA had given false statement regarding her age in self declaration at the

time of proposal. In view of complainant, his wife had not made any false statement regarding

her age. He had submitted self declaration as age proof in which her age has been mentioned

as 45 years, 3 years younger to the complainant. During Aadhar camp in village, her date of

birth was wrongly mentioned on card. As per the complainant he was a retired military person

and in his departmental card her age was 50 years 3 month at the time of proposal. After

repudiation of his wife`s death claim, he approached Review Committee of RIC but they upheld

the decision of the corporation. Being aggrieved with the decision of RIC, he approached this

forum for payment of death claim for redressal of his grievance.

Written reply/SCN:-

19. In their SCN/reply, RIC has stated that deceased life assured has given wrong information

about her age in proposal form. She deliberately did not disclose the material fact regarding her

correct age. With correct age, she was not insurable under the given plan. As per Aadhar card

deceased life assureds‟ date of birth was 01.01.1963 age being 52 years at the time of

proposal. This suppression of material facts during proposal stage clearly done with intent to

mislead the corporation. It has been decided by the Corporation to repudiate all the liabilities

and as per provision 45 of insurance act 1938 and refund of all premiums paid under the policy.

20. The complainant has filed a complaint letter, Ann VI A and correspondence with respondent


Pag

e23

21. I have heard Shri Sivam Maurya who is the son of complainant Sri Tribhuwan Prasad.

Tribhuwan Prasad died during pendency of this complaint hence I allowed Shri Sivam Maurya to

make the submission. I have also heard the respondent representative and perused the record.


22. Case relates to the death benefit claim of Munni Devi wife of Tribhuwan Prasad.

Undisputedly wife of complainant was insured. According to the respondent at the time of

commencement of the policy no proof of date of birth was available hence an affidavit was taken

and an extra premium was charged. Age of the DLA at the time of commencement of the policy

was shown as 45 years. DLA died in 09.09.2017. Death claim was repudiated on the ground

that the DLA had shown are wrong age in the proposal form. As per the Aadhar Card her date

of birth is shown as 01.01.1963. In the Voter ID Card her year of birth was shown as 1963.

Accordingly her age comes out more than 52 years as on the date of commencement of the

policy. On that age of 52 years policy in question could not be issued in her name.

23. Complainant submits that the age of DLA was rightly shown in the proposal form. Tribhuwan

Prasad husband of DLA was an army personnel. Identity Health Card was issued by Col. S S

Daliwal wherein the date of birth of Munni Devi was shown as 01.07.1965. It is a document

issued by a Competent Authority of the defence forces. Such identity card is issued only after

proper scrutiny by the army officers. Such cards could not be issued in a casual manner hence

the date of birth as shown in the card cannot be put in suspicion or disbelieved. Apart from the

identity card pathological report from the deceased from the Sarakar Diagnostics, Lucknow and

other diagnostics centre of Barabanki have been submitted wherein in the year 2017 in Bana

Imagine and Diagnostics report age is shown as 50 years. In Surya Hospital report of 2017 age

is shown as 50 years. All these documents are annexed with the complainant but in the SCN

none of these documents were disputed by the respondent insurance company. Hence these

documents cannot be dis-believed.

24. Aadhar Card is a document of identity. It is admitted case that at the time of commencement

of the policy no definite proof of age was available hence affidavit of age was taken. Hence the

age as shown in the Aadhar or Voter ID card could not conclusively be held as proof of age.

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Hence age could not be determined on the basis of these documents. Accordingly I am of the

view that the respondents have wrongly repudiated the claim of life to pay the same.


25. Complaint is allowed. Respondent are directed to make the payment of death benefit claim

in accordance with the rules and terms and conditions of the policy bond.






Smt. Shanti Devi…………………………..……..……....…………………. Complainant

V/S

Life Insurance Corp. of India …….………………………………………Respondent


1. Name & Address of the Complainant Smt. Shanti Devi

Jawahar Nagar

Kanpur

2. Policy No:

Type of Policy


237615297

Endowment assurance

01.07.2013



Late Praveen Kumar Chaudhry

Late Praveen Kumar Chaudhry

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4. Name of the insurer Life Insurance Corp. of India



health



9. Amount of Claim ---




2017



a) For the Complainant Smt. Shanti Devi (mother)

b) For the insurer Mr. Pramod Kumar Dixit



17. Smt. Shanti Devi (Complainant) has filed a complaint against Life Ins. Corp. of India

(Respondent) alleging that the death claim of his son was wrongly repudiated.

MS



18. As per complainant, the said policy was issued on the life of her son Late Praveen Kumar

Chaudhry for Sum Assured of Rs. 2,00,000/- on 01.07.2013 who died on 13.01.2015. RIC had

repudiated the death claim stating that DLA had given false statement regarding his health at

the time of proposal. In view of complainant, her son had not made any false statement

regarding his health. Complainant has also stated that she has given all papers regarding

Pag

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leave/medical of her deceased son to the insurer. After repudiation of her son`s death claim,

she approached different unit of RIC and also Review Committee of RIC but they upheld the

decision of company. Being aggrieved with the decision of RIC, she has approached this forum

for payment of death claim for redressal of her grievance.

Written reply/SCN:-

19. In their SCN/reply, RIC has stated that the said policy was issued after receiving of duly filed

proposal form with sum assured Rs.2,00,000/=, premium Rs. 28,337/= yearly, date of

commencement 01.07.2013. Life assured died on 13.01.2015 after 1 year 6 month 8 days from

issuance of policy. As perform E filled by employer from January 2012 to March 2013 deceased

life assured availed 71 days medical leave but these facts were not disclosed at proposal stage.

The claim was repudiated on the basis of suppression of material facts regarding his health by

the deceased life assured. ZCDRC has also withheld the decision of repudiation.

20. The complainant has filed a complaint letter, Ann. VI A and correspondence with respondent



Findings:-

22. Admittedly deceased life assured had taken a policy for a sum assured of Rs. 2.00 Lakhs

with commencement date 01.07.2013. Life assured died on 13.01.2015. Claim was repudiated

on the ground that the life assured had suppressed the material fact regarding his medical

leaves on the ground of his health within last 5 years. Complainant submits that although the


deceased life assured had taken the leaves in the year from 09.01.2012 to 19.01.2012,

09.04.2012 to 07.05.2012, 30.07.2012 to 05.08.2012, 24.12.2012 to 02.01.2013 and 25.02.2013

to 10.03.2013 but none of the leave was taken for any serious health ailments. The complainant

admits that the DLA was habitual of taking tobacco. All these facts were not mentioned in the

Pag

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proposal form. Leave applications along with the fitness certificate shows that the DLA was also

a patient of pyrexia but it was not mentioned in the proposal form.

23. Insurance policy or the contract of the insurance is based on the pleas of “Uberrina Fides.”

Insured is expected and responsible to narrate all the correct facts in the proposal form. If any

facts are concealed by him it is a breach of trust between insured and the insurer. Good faith is

the basis of contract of insurance. Deceased life assured had concealed the material facts

regarding the leave undertaken by him in the year 2012 and 2013 which was on health ground.

In such circumstances I am of the view that the respondents have rightly repudiated the claim

and refunded the premium which did not need any interference. Accordingly complaint is liable

to be dismissed.

Order:-





Pag

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Sri Sunil Kumar Srivastava….………………………….……..…….………Complainant

V/S

Shriram Life Insurance Co. Ltd………………………………..………………Respondent


1. Name & Address of the Complainant Sri Sunil Kumar Srivastava

Naini

Allahabad

2. Policy No:

Type of Policy


NP131703027675

Shriram New Shri Raksh

28.03.2017



Late Kusum Lata Srivastava

Late Kusum Lata Srivastava

4. Name of the insurer Shriram Life Insurance Co. Ltd.


6. Reason for repudiation/Rejection Renwal premium cheque dishonour


8. Nature of complaint Rejection of death claim

9. Amount of Claim S.A. Rs.4,64,000 /=

10. Date of Partial Settlement



2017



a) For the Complainant Sri Sunil Kumar Srivastava

b) For the insurer Mr. Anil Kant



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17. Sri Sunil Kumar Srivastava (Complainant) has filed a complaint against Shriram Life Ins. Co.

Ltd. (Respondent) alleging wrong repudiation of death claim.



18. Sri Sunil Kumar Srivastava has filed a complaint before this forum against Shriram Life Ins.

Co. Ltd. regarding wrong rejection of death claim of the policy issued on the life of his wife. As

per complainant, the said policy was issued on the life of his wife Late Kusum Lata Srivastava

for Sum Assured of Rs. 4,64,000/- on 28.03.2017 who died on 08.07.2018. Being nominee

under the policy the complainant has submitted death claims paper but the RIC had rejected the

death claim stating that at the time of death policy was in lapsed condition. The complainant

informed them regarding particulars of renewal premiums deposited , then the company replied

him that cheque deposited against renewal premium due for 2018 stands dishonored so nothing

is payable under the policy. Being aggrieved with the decision of RIC, he has approached this

forum for payment of death claim and for redressal of his grievance.

Written reply/SCN:-

19. In their SCN/reply, RIC has stated that on receipt of proposal form and other relevant

document the company has issued above policy on the life of deceased Kusum Lata Srivastava

with date 31.03.2017, sum assured Rs.4,64,000/= with annual premium of Rs.71,493/= for a

period of ten years with policy term 20 years. The next premium due under the policy was

received through cheque which was dishonored due to reason “Prohibiting

alterations/corrections on the cheque under CTS”. The said fact was informed to the

policyholder vide letter dated 04.04.2018 and requested her to pay renewal premium of the

policy to continue the benefits, but the premium was not paid by the policy holder and policy

was lapsed as on 31.03.2018. The nominee under the policy intimated the company that the life

assured died on 08.07.2018 and claimed the death benefit. Due to non-payment of renewal

premium policy was lapsed status on 31.03.2018 and death of the life assured occurred on

08.07.2018 which is after the policy was lapsed hence the question of death claim does not

arise at all.

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20. On hearing dated 18.02.2020, respondent was directed to produce original/copy of cheque

which was deposited by the complainant and receipt of letter dated 04.04.2018 communicating

the dishonor cheque. The complainant was directed to produce original counter foil of the


cheque book and also file the affidavit in support of the document which he would be file on the

next date of hearing. We are in receipt of e-mail dated 25.02.2020 in which RIC has

clarified regarding cheque number mentioned in their earlier submitted SCN. They informed that

cheque number mentioned as 045784 dated 16.03.2018 which was based on the entries made

on their system. As per our instructions they obtained copy of the bounced cheque with return

memo, on observing the same actual cheque number was 047845 other details were correct

and matching. The error occurred at data entry stage which was purely

inadvertent/typographical error and they regretted for the same.

21. The complainant has filed a complaint letter, Ann. VI A and correspondence with respondent



Findings:-

23. Claim was repudiated on the ground of non-payment of renewal premium which was due on

28.04.2018. Complainant is the husband of insured Kusum Lata Srivastava. At the very outset it

is relevant to mention that the policy was commenced on 28.03.2017. Deceased insured was

appointed as business associate in the Shri Ram Fortune Solutions Limited with an agency

code 209650 vide letter dated 25.03.2017. Cheque for renewal premium was deposited by the

complainant on 16.03.2018 but the same was dishonored on the ground that “alterations on

instruments other than date field –alteration correction are prohibited under CT”. Since the

cheque was dishonored respondent sent a letter to the insured 4.04.2018 communicating the

cheque bounce. A request was made for payment of premium. Premium was not paid.

Accordingly policy was lapsed. Deceased died on 08.07.2018. There is clear evidence on

record to show that the cheque for depositing the premium bounced thereafter renewal premium

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was not paid accordingly policy got lapsed. Unfortunately insured deceased died on 08.07.2018

but the nominee could not get any claim due to non-payment of renewal premium.

24. I do not find any merit in the complaint which is liable to be dismissed.


Order:-




Place: Lucknow (Insurance Ombudsman)



Mrs. Meenu Jaiswal………….……..……....……………………………………. Complainant

V/S

Star Union Dai-ichi-Life Ins. Co. Ltd.………………………..…………………………Respondent


1. Name & Address of the Complainant Mrs. Meenu Jaiswal

W/o Late Sri Ved Prakash Jaiswal

Lahartara

Varanasi

2. Policy No:

Type of Policy


00923364

SUD Life Elite Assure Plan

30.11.2015

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4. Name of the insurer Star Union Dai-ichi-Life Ins. Co. Ltd.


6. Reason for repudiation/Rejection Suppression of material fact regarding

illness


8. Nature of complaint Wrong Repudiation





2017



a) For the Complainant Mrs. Meenu Jaiswal

b) For the insurer Anis Aslam Kazi



17. Mrs. Meenu Jaiswal (Complainant) has filed a complaint against Star Union Dai-ichi-Life

Ins. Co. (Respondent) alleging wrong repudiation of death claim of her husband.

MS



18. Mrs. Meenu Jaiswal has filed a complaint on 03.08.2018 before this forum alleging that the

above death claim was wrongly repudiated by the insurance company. As per complainant the

said policy was issued on the life of her husband Late Sri Ved Prakash Jaiswal for S.A. Rs.

17,29,000/= on 13.11.2015 who died on 07.09.2017 in Popular Hospital Varanasi. She has

submitted death claim papers as required by the company but the company refunded the

premium amount deposited by her husband and death claim of her husband was repudiated

stating that DLA had given false statement regarding his health in proposal form, as he was

suffering from heart diseases before proposing the policy and his treatment was continued with

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SGPGI, Lucknow. The company has not produced any evidence to her. Then she has

requested to claim review committee of the RIC but they upheld the decision of the company.

Being aggrieved, the complainant approached this forum for payment of death claim and


Written reply/SCN:-

19. In their SCN/reply the respondent has stated that the company was in receipt of a death

claim under the policy along with claim form and relevant documents. The policy was issued on

the basis of information provided by DLA which was incorrect. Had DLA disclosed the details of

his medical history at proposal stage the company would have asked some more medical

formalities and maybe policy would not have been issued in favour of DLA. The claim was

repudiated by the company on 19.02.2018. The complainant had requested the claims review

committee vide her letter dated 13.03.2018 for re-considering the claim repudiation and decision

was upheld by the committee and accordingly communicated to the complainant. The company

has already refunded the premium amount to the complainant and death claim has been rightly

repudiated by the company owing to non-disclosure and misrepresentation of the material

information regarding the medical history by the DLA. As per provisions the company is not

liable to make any further claim amount demanded by the complainant.




RIC.


Findings:-

22. Admittedly deceased life insured Ved Prakash Jaiswal was insured with the respondent. He

died on 07.09.2017. Date of commencement of policy bond was 30.11.2015. Annual premium

was Rs. 1,62,878/-. Claim was repudiated on the ground that the deceased insured was already

suffering from cardiac ailment. He was admitted on 17.04.2006, 11.04.2008, 06.03.2010 and

26.04.2011 in Sanjay Gandhi Postgraduate Institute of Medical Sciences for heart related

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ailments but in the proposal form he did not disclose his prior ailments. Accordingly the claim

was repudiated. Discharge summary of Sanjay Gandhi Postgraduate Institute of Medical

Sciences, Lucknow from 17.04.2006 to 02.05.2006, 11.04.2008 to 17.04.2008, 06.03.2010 to

16.03.2010, 26.04.2011 to 30.04.2011 is submitted which clearly shows that the deceased life

insured from suffering from heat ailment prior to commencement of the policy but this fact was

concealed by him, accordingly claim was rightly repudiated by the respondents. Premium paid is

also refunded. Accordingly I do not find any merits in the complaint and is liable to be dismissed.

Order:-


24. Let copy of award be given to both the parties.





Mrs. Alka Singh………………..……....………………………..……………. Complainant

V/S

L.I.C. of India……..…...……………..……………………………..…………...Respondent


1. Name & Address of the Complainant Mrs Alka Singh.

W/O Late Sachidananad Singh

Vill.- Majhgawan Kalan

Post-Kutir Chakkey

Dist.- Jaunpur-222146

2. Policy No:

Type of Policy

DOC /DOR

286704975

Bima Gold Plan

28.03.2009

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DOD

Duration of policy

08.06.2010

01 year 02 months &11 days



Sachidananad Singh

Sachidananad Singh

4. Name of the insurer L.I.C. of India


6. Reason for repudiation/Rejection Illness prior to taking policy





11. Amount of relief sought Death claim amount of Rs.300000/-

12. Complaint registered under Rule Rule No.13(1)(b)of Insurance Ombudsman

Rule 2017

13. Date of hearing/place 20.02.2020 at 10.15 A.M.


a) For the Complainant Mrs. Alka Singh

b) For the insurer Mr. Harish Chandra Singh Brijwal



17. Mrs Alka Singh. (Complainant) has filed a complaint against LIC of India (Respondent)

alleging that her husband‟s Death Claim was wrongly repudiated.

YKS



18. Complainant has stated that her husband had taken a policy no.286704975 on his life on

28.03.2009 under T-T 179-20 for Rs.300000/-Sum Assured from LIC Of India. Unfortunately he

expired on 08.06.2010.His death claim was repudiated by Divisional office on the ground that he

was ill before taking the policy. She further stated that her husband was never ill and was quite

healthy. He never consulted any Physician. Actually her husband went to Bank to deposit some

amount and there he fell down. Immediately he was rushed to KGMC Hospital Lucknow and

there she came to know that he met with Brain Hemorrhage and expired there. After that he

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also appealed before Zonal Manager of LIC who also upheld the previous decision. Being

aggrieved, the complainant approached this forum for the redressal of his grievance.

Written reply/SCN:-

19. In SCN/reply dated 28.12.2018, RIC has stated that DLA had taken a policy no. 286704975

of Rs. 300000/- with 179-20 on 28.03.2009. He expired on 08.06.2010. Hence duration was only

01 year 02 months & 11 days. Hence an enquiry was made and found that DLA was ill before

taking the policy. He had taken treatment from SGPGI Lucknow and cause of death was MCA

with RHD with MS with PAH DLS. DLA was also suffering from Hypertension for last one and

half years. Hence his claim was repudiated. Claimant has also appealed before Zonal Manager

who also upheld the decision.

20. The complainant has filed a complaint letter, and Annexure VI A and correspondence with



Findings:-

22. Deceased life assured Sachidananad Singh had taken up policy under LIC „New Bima Gold

Policy‟. Date of commencement was 28.03.2009. Sum assured was Rs. 3,00,000/-. DLA died on

08.06.2010. Claim was submitted by the nominee i.e. his wife which was repudiated on the

ground of concealment of fact that the DLA was suffering from Hyper Tension prior to taking up


the policy. This decision was also confirmed by ZCRC on 21.11.2011 which was also allegedly

communicated to the complainant vide letter dated 09.01.2012. It appears that no

communication was received by the complainant so she again moved the application before the

respondents. Thereafter vide letter dated 19.11.2018 she was communicated about the earlier

decision dated 09.01.2012. Thereafter she preferred a complaint before this forum. Delay in

moving before this forum is duly explained and is accordingly condoned.

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23. It is submitted that the DLA was not suffering from any ailment of Hyper Tension. He was

hail and hearty person of 27 years of age. He suffered some stroke in the bank. No material

information was concealed by him.

24. The sole ground for repudiation is that the DLA was suffering from hyper tension. In the bed

head ticket of the DLA at the time of admission in the SGPGI Lucknow on 05.06.2010 it is

mentioned that he has a history of hyper tension for one and half year but it is also mentioned

that documents are not available and he was not taking any medicine. He was also not suffering

from any other ailment. He was also having intermittent chest pain for about 2 years but there is

no material on record to substantiate the history of ailment. Even for hyper tension there is no

document to establish that he was an old case of hyper tension. It cannot be believed that

deceased was an old case of hyper tension. Repudiation was solely made on the ground of

concealment of hyper tension but it could not be established on record. Even in SGPGI,

Lucknow it is mentioned in the history that no document regarding ailment of hyper tension is

available. He was also not taking any medicine for the same. If the deceased would have been

suffering from hyper tension he must be taking some medicines but it is not established from the

material available on record. Claim cannot be repudiated merely on the surmises and

conjectures. Hence no material fact was concealed by the insured at the time of taking of the

policy. Accordingly the repudiation is bad in law. Complainant is entitled for the death benefit

claim of his husband.


Order:-

25. Complainant is allowed. Respondent are directed to make payment of claim along with

interest at the rate of 8.25 percent per annum from the date of submission of claim till the date

of actual payment, within a period of 30 days.




Pag

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Mrs. Bindu Mishra ………………..…………………………......………………. Complainant

V/S

L.I.C. of India……..…...……………..………..……………………….…..….……...Respondent


1. Name & Address of the Complainant Mrs. Bindu Mishra

W/O Late Ram Krishna Mishra

87 G/5, Sarvodaya Nagar

Allapur

Allahabad

2. Policy No:

DOC /DOR

DOD

Duration of policy

315892002 , 315891936 , 314419875

314413399 & 314379881

15.05.2015 ,12.05.2015 , 25.03.2013

29.11.2012 & 12.11.2010

28.08.2015

03m 14 days ,03m 15 days ,2y 5m 3days

2y 8m 29 fays & 4y 8m 16 days / 2y 8 m 16

days(after revival)



Ram Krishan Mishra (315891936 for PWB)

Ram Krishan Mishra



6. Reason for repudiation/Rejection Alcoholic



9. Amount of Claim 90000/- + 600000/- + 503480/- + 200000/-

+ 200000/(TRIPAL RISK)- Total 2803480/-

10. Date of Partial Settlement Hr All premiums were refunded under policies no.

315892002, 314419875, 314413399 and 314379881.

11. Amount of relief sought Death claim amount

12. Complaint registered under Rule Rule No.13(1)(b)of Insurance Ombudsman Rule

2017



c) For the Complainant Mr. Amaresh Mishra

d) For the insurer Mr. Sukhbir Mishra



Pag

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17. Mrs. Bindu Mishra Complainant has filed a complaint against LIC of India (Respondent)

alleging that her husband‟s Death Claim was wrongly repudiated.


18. Complainant has stated that her husband had taken five policies no. 315892002, 315891936,

314419875, 314413399 and 314379881 on his life. Policies were taken by deceased in year

2010, 2012, 2013 and 2015.Her husband expired on 28.08.2015. Her husband was a reputed

businessman of Allahabad and deposited all premiums in time. But his death claim was

repudiated on the sole ground that deceased was habitual of taking Alcohol which was not

correctly disclosed by him in the proposal forms. Claimant has further stated that repudiation

order was quite contrary to the medical reports and was illegal, arbitrary and is against the

provisions of settled law. Being aggrieved, the complainant approached this forum for the


Written reply/SCN:-

19. In SCN/reply dated 2925.05.2018, RIC has stated that DLA had taken five policies under

different plan with a total risk of Rs. 2803480/-(Policy no. 315891936 was on the life of

Shambhavi daughter of DLA for PWB). While processing the claim, Company found that DLA

was not in Good health on the date of proposals/revival.DLA had been treated in Dwevedi

Medical and Research Center during the period 24.04.2015 to 26.08.2015 for Alcoholic liver

Cirrhosis and Gastro intestinal bleeding with Heptic encephalopathy. Further DLA was referred to

Medanta Hospital. Death summary of Medanta states that DLA was known case of Alcoholic liver

disease with decomposition. He had been suffering from decompensate chronic liver disease,

massive hematemesis, post (EVL) failed and acute kidney injury. It was also mentioned in social

history „‟Daily alcohol intake for 8-10years‟‟. On the above ground, claim under above policies

were repudiated. However all premiums were refunded under policies no. 315892002,

314419875, 314413399 and 314379881. Decision was further reviewed by ZCDRC Kanpur and

they have also upheld the decision. Further RIC vide their letter dated 10.02.2020 has informed

that as per amended Insurance Rules 2015, death claim under policy no. 314379881, 314413399

& 314419875 have been admitted by the competent authority.

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20. The complainants have filed a complaint letter Annexure VI A, along with other relevant

papers while respondent has filed SCN with enclosures.


Findings:-

22. Deceased life assured Ram Krishna Mishra was insured with the LIC. With 5 policies out of

which in policy no. 314379881, 314413399 and 314419875 the claim has been accepted under

amended section 45 Insurance Act vide revised SCN dated 10.02.2020. Although payment has

yet not been made.

23. In Policy no. 315892002 and 315891936 claim was repudiated on the ground of

concealment of material fact regarding illness. These policies were taken by the deceased on

14.05.2015 and 13.05.2015 respectively. Date of death of DLA is 28.08.2015. Accordingly on

enquiry being made it was revealed that the deceased was treated at Medanta Hospital,

Gurgaon. In the Death summary it is mentioned that:-

“He was a known case of Alcoholic liver disease with decomposition. Patient was urgently

admitted in ICU under gastro team, critical care team reviewed the patient and treatment was

started. Urgent UGI Endoscopy was done with showed 3 columns of large varices with active

bleeding and EVL was done. Nephro review was taken for AKI and severe metabolic acidosis

and SLED was started. The bleeding was not controlled even by banding. Hence, TIPPS was

planned and relatives were prognosticated. However due to high vasopressor support,

circulatory shock TIPPS was not possible.

On 28.08.2015 at around 6:20pm patient had cardiac arrest, CPR was started according to the

ACLs protocol but despite all above efforts patient could not be survived and declared expired at

6:41 pm on 28.08.2015.”

24. In the proposal form the ailment was not mentioned. Even it was not mentioned that the

deceased was alcoholic. It amounts to concealment of material facts. Contract of insurance is

based on the principle of good faith between the parties. Any concealment of fact nullifies the

Pag

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contract. Accordingly the claim was rightly repudiated which does not require any interference.

Order:-







Mr. Jagdish Narayan Gupta……………….............………………. Complainant

V/S

L.I.C. of India……..…...……………………….………..………..…..………...Respondent


1. Name & Address of the Complainant Mr.Jagdish Narayan Gupta

S/O Late Ghanshyam Gupta

H.No. 76/232; Coolie Bazar

Sabzi Mandi; Badshai Naka

Dist-Kanpur-208001

2. Policy No:

Type of Policy

DOC /DOR

DOD

Duration of policy

232325433

Jeevan Surabhi Plan

28.04.2000

17.06.2004

03 years 07 months 07 days



Alok Kumar Gupta

Alok Kumar Gupta

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6. Reason for repudiation/Rejection Intentional murder is not Accident


8. Nature of complaint DA B Payment


10. Date of Partial Settlement BSA paid

11. Amount of relief sought DAB claim amount


2017



e) For the Complainant Absent

f) For the insurer Mr. P. K Dixit



17. Mr.Jagdish Narayan Gupta (Complainant) has filed a complaint against LIC of India

(Respondent) alleging his son‟s Accidental Death Claim was wrongly rejected.



18. The complainant has stated that his son had taken a policy no. 232325433 on his life.

Unfortunately he was murdered on 17.06.2004. His death claim for Basic sum assured had already

been made but accidental claim is not paid. LIC has rejected his claim on the ground that it was an

Intentional killing which is not covered under accident benefit. Claimant has further stated that in

this case, Hon‟ble court has passed his judgment and in the order they have not mentioned that it

was an intentional killing. Hence his claim was wrongly rejected. The fact of the case is DLA Alok

Kumar Gupta was a Businessman and had some dispute for Money. As per Newspaper cutting,

DLA was kidnapped and his dead body was found in closed room of neighbor‟s house. But in FIR,

lodged by DLA‟s brother who is a lawyer, it is mentioned that accused were sitting on the chest of

his brother and they have murdered his brother. Police has arrested all accused and charge

sheeted six persons. Hon‟ble court has passed his order and copy of the same is enclosed. After

that she also appealed before Zonal Manager of LIC who also upheld the previous decision. Being

aggrieved, the complainant approached this forum for the redressal of his grievance.

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19. In SCN/reply dated 30.05.2019, RIC has stated that DLA had taken a policy no.232325433 for

Rs. 100000/- with T-T 106-15(12) on 28.04.2000. BSA under the policy was paid to the nominee

but DAB was repudiated because the cause of death was pre-planned and intentional murder and

accused were convicted. Hence it is not an accident. Decision of repudiation of DAB was also

upheld by ZCDRC.

20. The complainants have filed a complaint letter Annexure VI A, along with other relevant papers


21. Despite notice complainant is not present. Have heard the respondent representative and

perused the record.


Findings:-

22. Complainant has been made on the ground that the Double Accident benefit under the policy

of Alok Kumar has been declined by the LIC while it should have been covered under accident

death. Undisputedly deceased Alok Kumar Gupta was covered under the policy. As per the

judgment of Special Judge (SC/ST Act), Kanpur Nagar in Session Trial No. 670of 2005 State Vs

Pannu Alias Purshotam Gupta and others under section 147,148, 149, 302 IPC PS Badasahi

Naka, District, Kanpur Nagar dated 15.12.2010 deceased Alok Kumar Gupta was murdered on

17.06.2004 at about 4:30 P.M. by the accused who assaulted him with deadly weapon with an

intention to commit murder. Accused were convicted and sentenced to life imprisonment by the

trail court. Double Accident Benefit claim was repudiated on the ground that it was an intentional

murder. In my opinion the order of repudiation of claim over Double Accident Benefit did not

require any interference. Complaint is liable to be dismissed.

Order:-


24. Let copy of this award be given to both the parties.



Pag

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Mrs. Neelu Singh ………………..……..........................………………. Complainant

V/S

L.I.C. of India……..…...……………..………..…………………..…..………...Respondent


1. Name & Address of the Complainant Mrs. Neelu Singh

C/O Sri Vijay Kumar Singh

Forvisganj

Pant Nagar

Dist.- Gonda (U.P.)

2. Policy No:

DOC /DOR

DOD

Type of policy

314446948 , 314446949 , 314446645 &

315712665

28.06.2015 , 28.06.2015 , 18.09.2013 &

28.11.2013

05.02.2018

First Two Policies for PWB & Last Two Jeevan

Anand



Abhinav Singh,Abhigyan Singh & Amit Kumar

Singh

Amit Kumar Singh


5. Date of Repudiation/Rejection Case Not Decided

6. Reason for repudiation/Rejection --



9. Amount of Claim 200000/- + 200000/- + 100000/- +200000/-

Total 700000/-

10. Date of Partial Settlement Hr



2017



g) For the Complainant Absent

h) For the insurer Mr. Sukbhir Singh



Pag

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YKS


17. Mrs. Neelu Singh Complainant) has filed a complaint against LIC of India (Respondent)

alleging her husband‟s Death Claim is not settled.


18. The complainant has stated that her husband had taken four policies no. 314446948,

314446949, 314446645 & 315712665. First two policies were taken on her son‟s life with PWB

and last two policies on his life. Policies were taken by him in year 2013 and 2015.Unfortunately

her husband expired on 05.02.2018. Being the nominee under the policies, she has submitted

all the claim papers with the company, but claim is not settled till date. Being aggrieved, the

complainant approached this forum for the redressal of his grievance.

Written reply/SCN:-

19. In SCN/reply dated 19.11.2018, RIC has stated that:-

A). Policy no.314446948 was issued on the life of Abhinav Singh and Amit Kumar Singh was

proposer. Policy was issued with PWB and claim papers are not submitted by claimant. Hence

decision is not taken.

B). Policy no.314446949 was issued on the life of Abhigyan Singh and Amit Kumar Singh was

proposer. Policy was issued with PWB and claim papers are not submitted by claimant. Hence

decision is not taken.

C). Policy no. 314446645 was issued on the life of Ashok Kumar Singh and this policy number

may be wrong as Claimant has no relation with this policy.

D). Policy no. 315712665 was issued on the life of Amit Kumar Singh and death claim of

Rs.249800/- was paid to nominee.

Further as per revised SCN dated 10.02.2020, RIC has informed that –

A). Death claim of Rs. 249800/-under policy no. 315715665 has been paid on 31.10.2018.

B). Death claim of Rs. 280400/- under policy no. 314446945 has been paid on 13.09.2018.

C). PWB under policy no. 314446948 & 314446949 have been admitted by competent authority.



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21. Despite notice complainant is not present. I have heard the respondent representative and

perused the record.

Findings:-

22. In view of the e-mail from the respondent insurance company dated 10.02.2020 wherein it is

mentioned that the payment of 2 policies no. 315715665 and 3144446945 have been made by

the LIC while remaining 2 policies no. 314446948 and 314446949 PWB has been admitted by the

Competent Authority. Accordingly in view of the mail complaint is disposed off.

Order:-

23. Complaint is disposed off.




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Mrs. Pramila Singh ………………..……..............................………………. Complainant

V/S

L.I.C. of India……..…...……………………….……………..………..…..………...Respondent


1. Name & Address of the Complainant Mrs. Pramila Singh

W/O Late Raj Kumar Singh

Vill & Post- Kataiya Newada

Dist- Pratapgarh

2. Policy No:

Type of Policy

DOC /DOR

DOD

Duration of policy

313517142

Jeevan Raksha Plan

20.01.2009

15.07.2015



Raj Kumar Singh

Raj Kumar Singh

4. Name of the insurer L.I.C.of India


6. Reason for repudiation/Rejection Intentional murder is not Accident


8. Nature of complaint DA B Payment


10. Date of Partial Settlement BSA paid under both policies



2017



i) For the Complainant Mrs. Pramila Singh

j) For the insurer Mr. Sukhbir Singh



17. Mrs. Pramila Singh (Complainant) has filed a complaint against LIC of India (Respondent)

alleging that her husband‟s Accidental Death Claim was wrongly repudiated.

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18. Complainant has stated that her husband had taken a policy no. 313517142 on his life.

Unfortunately he was murdered on 15.07.2015. According to the FIR on 15.07.2015 at

about8:30 A.M deceased Raj Kumar Singh came to U.P Bombay Dhaba along with truck no.

UP33802639. One unknown person was with him. Both of them had lunch. Thereafter, there

was some dispute between them on account of cleaning of truck. Deceased Raj Kumar Singh

abused the cleaner. Thereafter he slept while the cleaner was viewing television. At about 1:00

P.M cleaner started giving blows of steal wheel spanner on the head of deceased Raj Kumar

Singh. On hearing the voice of Raj Kumar Singh, other persons ran away to the sight then

cleaner gave another blow to Raj Kumar Singh. Cleaner try to run away but was appended. Raj

Kumar Singh Died. Double accident benefit claim was repudiated by the respondent on the

ground that it was not a case of accident rather intentional murder. Double accident benefit is

not payable. Hence DAB claim was repudiated by Divisional office. After that she also appealed

before Zonal Manager of LIC who also upheld the previous decision.

19. Being aggrieved, the complainant approached this forum for the redressal of his grievance.

Written reply/SCN:-

20. In SCN/reply dated 12.10.2018, RIC has stated that DLA had taken a policy no.313517412

for Rs. 100000/- with T-T 91-30 on 28.03.2006.Basic Sum Assured under the policy was paid to

the nominee but Double Accident Benefit Claim was repudiated. Cause of death was pre-

planned and intentional murder and accused was convicted. Hence it is not an accident.

Decision of repudiation of Double Accident Benefit was also upheld by ZCDRC.




Pag

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Findings:-

23. Deceased assured Raj Kumar Singh was murdered by one Mohd. Aamir Shekh on 15.07.2015.

Deceased was truck driver while the accused was the cleaner. Some altercation took place

between them resulting in the murder of deceased. FIR was lodged and accused faced the trial

under section 302 IPC. He was convicted and sentenced under section 302 for imprisonment for

life by Additional Session Judge, Jal Gaon in session case no. 126 of 2015. It was held that the

deceased was attacked by the accused with an intention to kill him. Accordingly the LIC made the

payment of sum assured to the nominee but the grievance is regarding nonpayment of Double

Accident Claim.

24. It is submitted by the complainant that the death was caused due to an accident. Accused had

no intention to kill. I am unable to accept the contention. In the FIR as well as the judgment of

session‟s court, it was held that accused with an intention to kill the deceased inflicted the blows

upon the deceased. Accordingly the death of the deceased was homicidal. It was especially held in

the page 20 of the judgment that death of Raj Kumar Singh was neither accidental nor suicidal.

Accordingly I am of the view that the LIC has rightly not paid the Double Accident Benefit.

Complaint is devoid of merit and liable to dismissed.

Order:-





Pag

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Mr. Ram Achal Patel………………..……………………….....………………. Complainant

V/S

L.I.C. of India …..…...……………..………..……………………..…..……….. Respondent


1. Name & Address of the Complainant Mr. Ram Achal Patel

Vill-Paraupur

Post- Shudnipur

Dist.- Jaunpur- 222161

2. Policy No:

Type of Policy

DOC /DOR

DOD

Duration of policy

245564244

Jeevan Shikhar (Single Premium)

30.03.2016

26.03.2017

11 months 28 days



Neeraj Kumar Patel

Neeraj Kumar Patel



6. Reason for repudiation/Rejection Proof of Accident is not available.




10. Date of Partial Settlement -



2017



k) For the Complainant Mr. Ram Achal Patel

l) For the insurer Mr. Shri Prakash



17. Mr. Ram Achal Patel Complainant) has filed a complaint against LIC of India (Respondent)

alleging that his son‟s death Claim was wrongly repudiated.

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e51

YKS



18. The complainant has stated that his son had taken a policy no.245564244 on 28.03.2017

under T-T 837-15 for 817100/-. Unfortunately he met with a train accident while he was crossing

the train track on 26.03.2017.His son expired at the spot. But LIC has repudiated his death claim.

Complainant had also appealed before ZCDRC KANPUR and COCRC MUMBAI, and both had

upheld the decision of repudiation. Being aggrieved, the complainant approached this forum for the


Written reply/SCN:-

19. In SCN/reply dated 23.05.2018,the respondent have stated that policy no. 245564244 was

issued on the life of Neeraj Kumar Patel for the sum assured of Rs. 817100/- on 30.03.2016 with a

single premium of Rs.81710/-. Claim was lodged by Mr.Ram Achal Patel who is the father of DLA.

The date of death reported 26.03.2017 and death certificate was submitted. According to enclosed

papers submitted by claimant, it was found that DLA died due to dubious Rail Accident. But FIR,

Panchnama and PMR were not submitted. The Suicide clause under the policy was operative.

Hence claim was repudiated by Divisional Office. Decision was further reviewed by ZCDRC

Kanpur & COCRC Mumbai and they have also upheld the decision.


papers while respondent filed SCN with enclosures.


Findings:-

22. DLA namely Neeraj Kumar Patel was insured under the plan 837-15 (01). Date of

commencement was 28.03.2016. Sum assured Rs. 817100/-, single premium paid Rs.78710/-. He

died on 26.03.2017 while crossing the railway line. Claim was repudiated by the respondent which

was upheld by ZCDRC on 31.10.2017 and COCRC on 24.02.2018.

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23. Death certificate of the deceased issued by the Registrar Department of Panchayat, Paraupur,

Mariyahoo district Jaunpur shows that the date of death is 26.03.2017. The only point to consider

as to whether it is a case of suicide or accidental death?

24. Complainant could not produce any material to show that it is a case of accident rather it is

admitted that while crossing the railway line all of a sudden train arrived and deceased came in

contact with the running train. Consequently he died. In this case neither the FIR was lodged nor

postmortem was conducted nor any information was sent to the police. It is noteworthy that the

complainant who is a father of the deceased is an agent of the LIC. In such circumstances the

above formalities attains more important. On the basis of discussion made above I am of the view

that the respondent have rightly repudiated the claim however in view of circular no:-

CO/PD/80/DT. 5/1/2016, U AND R/132/2016 dt 11/1/2016, co/pd/85 dt 12/4/2016. 90 percent of

the premium paid should be refunded to the complainant.

Order:-

25. Complaint is dismissed. Respondent shall refund 90 percent of the premium paid to the

complainant within 30 days.




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Mr. Ram Lal ………………..…………………………………....………………. Complainant

V/S

L.I.C. of India……..…...……………..…………………..………..…..………...Respondent


1. Name & Address of the Complainant Mr. Ram Lal

Vill.-Nawabpur Urf Khanpur

Post- Mau Aiym

(Nai Bazar)

Dist.- Allahabad -212507

2. Policy No:

Type of Policy

DOC /DOR

DOD

Duration of policy

314396796

Endowment Plan

15.12.2011 / 29.05.2015

02.06.2015

03y 05 m & 17 days / 03 days



Anara Devi

Anara Devi



6. Reason for repudiation/Rejection Difference in Age




10. Date of Partial Settlement -



2017



m) For the Complainant Mr. Ram Millan

n) For the insurer Mr. Sukbhir Kumar



17. Mr. Ram Lal Complainant) has filed a complaint against LIC of India (Respondent) alleging

that death Claim of his wife was wrongly repudiated.

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YKS


Brief Facts of the Case:-

18. The complainant has stated that he had taken a policy no.314396796 on 15.12.2011 on the

life of his wife Smt. Anara Devi from LIC of India. He further stated that her wife‟s age was 45

years at the time of taking policy and LIC had charged Extra Premium for age proof and then

admitted the age. Unfortunately his wife expired on 02.06.2015.During investigation, Enquiry

officer had noted her age 60 years which is totally wrong. He had submitted Pariwar Register for

age proof where date of birth is mentioned 1966. But her death claim was repudiated by

Divisional office on the ground that there is a difference in age in Voter Card and Self

declaration. After that he also appealed before Zonal Manager of LIC who also upheld the

previous decision. Being aggrieved, the complainant approached this forum for the redressal of

her grievance.

Written reply/SCN:-

19. In SCN/reply dated 19.11.2018, RIC have stated that the above policy was issued on the life

of Anara Devi. DLA had taken insurance by understatement of age by 15 years, with actual

age.DLA was not insurable. DLA deliberately did not disclose the material fact regarding his

correct age. Had she disclosed her correct age at the time of submitting the proposal, the same

would not have been accepted at all as DLA was 60 years old and not insurable at that time.

Hence her death claim was repudiated. Decision was further reviewed by ZCDRC Kanpur and

they have also upheld the decision.

20. The complainants have filed a complaint letter annexure VI A, along with other relevant


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21. I have heard Sri. Ram Millan who is the representative son of complainant Ram Lal and the

respondent representative and perused the record.

Findings:-

22. Claim was repudiated on the ground of concealment and mis-representation of actual age of

insured deceased. At the very outset I would like to observe that Ram Millan who is the son


of the deceased has given in writing that his date of birth is 03.03.1978. In the policy bond and

the proposal form age of the insured is shown as 45 years on 15.12.2011. The Voter ID card of

the deceased shows the age of deceased on 01.01.1995 as 44 years. As per the statement of

Ram Millan his date of birth is 1978. Accordingly it is absolutely clear that age of the deceased

was wrongly shown as 45 years as on the date of proposal. Accordingly claim is rightly

repudiated. Complaint is liable to be dismissed.

Order:-





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Mr. Santosh Kumar Srivastava………………..………..……......………………. Complainant

V/S

L.I.C. of India …..…...……………..………..………..…………………………….. Respondent


1. Name & Address of the Complainant Mr.Santosh Kumar Srivastava

S/O Sri Ram Babu

Vill.- Usri

Post- Maikhan

Phoolpur

Dist.- Allahabad- 212402

2. Policy No:

Type of Policy

DOC /DOR

DOD

Duration of policy

311133624

Bima Gold Plan

28.03.2006

30.11.2014

8 y 7 m 29 days



Savita Srivastava

Savita Srivastava



6. Reason for repudiation/Rejection Dab is not payable in Suicide


8. Nature of complaint DAB Claim


10. Date of Partial Settlement BSA Paid



2017



o) For the Complainant Absent

p) For the insurer Mr. Sukhbir Singh



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e57

17. Mr.Santosh Kumar Srivastava has filed a complaint against LIC of India (Respondent) alleging

that her wife‟s Death Accident Benefit Claim was wrongly repudiated.



18. The complainant has stated that her wife had taken a policy no.311133624 for Rs. 50000/-

and under T-T 174-20. Unfortunately she was murdered on 30.11.2014.Payment of basic sum

assured under the policy has been made by L.I.C. but DAB claim was rejected on the ground that

it is a case of Suicide (Self immolation) which is not covered under Accidental death.

Complainant has further stated that it is a case of murder and accused are charge sheeted under

SECTION 302 IPC.He has also submitted case diary of the court. Complainant had also

appealed before ZCDRC KANPUR, and they had also upheld the decision of repudiation. Being

aggrieved, the complainant approached this forum for the redressal of her grievance.

Written reply/SCN:-

19. In SCN/reply dated 20.08.2018, the respondent have stated that policy no.311133624 was

issued on the life of Savita Srivastava for the sum assured of Rs. 50000/-. Claim was lodged by Mr.

Santosh Kumar Srivastava who is the husband of DLA. The date of death as reported is 30.11.2014.

FIR, Panchnama, PMR and Police charge sheet was submitted. According to enclosed papers

submitted by claimant; it was found that Deceased Life Assured had committed Suicide. Hence

Death Accident Benefit claim under the policy was repudiated as Suicide is not cover under

Accidental death. Decision was further reviewed by ZCDRC Kanpur and they have also upheld the

decision.



21. Despite notice complainant is not present. I have heard the respondent representative and

perused the record.

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Findings:-

22. It is a case where deceased insured Savita Srivastava died. The FIR was lodged by her

husband. Charge sheet was submitted under section 306 IPC. Trial is still pending before the

COMPLAINT NO: LCK-L-029-1819-0423 Order No. IO/LCK/A/LI/0367 /2019-20

Competent Court. Complainant submits that the deceased died in an accident. Police has

submitted a manipulated report. Claim was repudiated on the ground that it was not a case of

accident rather suicide by self immolation. It is note-worthy that the trial is still pending before

the Competent Court. At this stage it would not be proper to give any finding as to how

deceased died. It would be appropriate that the respondent should decide the claim afresh after

the decision of the session trial pending before the Competent Court in accordance with law.

Order:-

23. Complaint is disposed off with a direction to respondent LIC to dispose of the claim of the

complainant after decision of the Session trial in accordance with law after affording an

opportunity of hearing to the complainant. If the complainant is not satisfied with the decision of

LIC he may move again in accordance with rules.




Pag

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Mr. Sehdev………………..………………………………......………………. Complainant

V/S

Life Insurance Corporation of India…………..…………………..…………...Respondent


1. Name & Address of the Complainant Mr. Sehdev

Vill.- Rajapur

Post -Bharatganj

Dist.-Allahabad (U.P.) -212104

2. Policy No:

Type of Policy

DOC /DOR

DOD

Duration

310699467

Jeevan Surabhi Plan

13.07.1999 /10.02.2017

18.02.2017

08 days from revival



Vijay Kumar Maurya

Vijay Kumar Maurya



6. Reason for repudiation/Rejection Illness prior to revival.




10. Date of Partial Settlement Paid up value and Refund of revival

premium

11. Amount of relief sought Death Claim of increased sum assured

12. Complaint registered under Rule Rule No.13(1)(b)of Insurance Ombudsman

Rule 2017



a) For the Complainant Mr. Sehdev

b) For the insurer Mr. Sukhbir Kumar



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17 Mr. Sehdev (Complainant) has filed a complaint against Life Insurance Corporation of India

(Respondent) alleging that he has not received the increased sum assured on her son‟s Death

claim .

YKS



18. The complainant has stated that his son had taken a policy no. 310699467 for Rs 50000/-

Sum Assured on 13.07.2009 under Jevan Surabhi plan on his life from Life Insurance

Corporation of India. Unfortunately he expired on 18.02.2017. Being the nominee, he had

submitted all the claims papers to the Company. But LIC has paid death claim only on basic

sum assured, but as per policy condition basic sum assured increased by 50% after every five

years but he has not received the increased sum assured under the policy. Being aggrieved, the

complainant approached this forum for the redressal of his grievance.

Written reply/SCN:-

19. In SCN/reply dated 29.04.2019, RIC has stated that Policy no.2310699467 was issued on

the life of Vijay Kumar Maurya for Rs. 50000/- sum assured under T-T 108-25(18) on

13.072009. DLA did not deposit renewal premium regularly. Therefore policy became lapsed but

was revived on the basis of DGH on 10.02.2017 by depositing three half yearly premiums.

Respondent has received death claim intimation from the Complainant stating that his son had

passed away on 18.02.2017. As duration of policy from revival was only 08 days, hence an

enquiry was made and found that DLA had withheld correct material information regarding his

health at the time of effecting the revival of policy with the respondents. Hence revival was

repudiated with refund of premiums deposited for revival and paid up value. Claimant has also

appealed before ZCDRC who also upheld the decision.

20. The complainant has filed a complaint letter, Annexure VI A along with other relevant papers

while respondent has submitted SCN with enclosures.


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Findings:-

22. Date of commencement of the policy was 13.07.1999. It was a money back policy wherein 4

installments of survival benefits total amounting to Rs. 40,000/- were paid to the policy holder.


23. 3 half yearly premium for revival, were paid on 10.02.2017 while the insured died on

18.02.2017. At the time of revival in the declaration of good wealth, no ailments were mentioned

while the insured was suffering from RHD severe since 2001. He was also treated in AIIMS,

Delhi. All these material facts were not disclosed in the DGH submitted by the insured. He died

within 8 days from the date of revival of the policy. Main contention of the complainant is that an

increase in the sum assured to the extent of 50 percent on every 5th year be also paid to them.

Although the insurance company has paid Rs. 59611/- as paid up value and bonus since the

policy was in lapse mode on the date of death. Accordingly benefit of increase in sum assured

could not be given. Accordingly complaint lacks merit and liable to be dismissed.

Order:-





Pag

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Mrs. Sunita Singh………………..………………………........………………. Complainant

V/S

L.I.C. of India …..…...……………..………..……………….……..…..……….. Respondent


1. Name & Address of the Complainant Mrs. Sunita Singh

W/O Late Yashwant Singh

Fatehpur Sikander

Phullanpur , Bikapur

Dist.- Gazipur- 233001

2. Policy No:

Type of Policy

DOC /DOR

DOD

Duration of policy

287613341

Jeevan Anand Plan

28.02.2011/ 22.09.2015

23.08.2017

6y 5m 19 days / 01 y 11 m 01 days



Yashwant Singh

Yashwant Singh



6. Reason for repudiation/Rejection Intentional killing is not an Accident


8. Nature of complaint DAB Claim


10. Date of Partial Settlement BSA Paid on 16.12.2017



2017



q) For the Complainant Mrs. Sunita Singh

r) For the insurer Mr. Shri Prakash



17. Mrs. Sunita Singh Complainant) has filed a complaint against LIC of India (Respondent) alleging

her husband‟s DAB Claim was wrongly repudiated.

Pag

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YKS



18. The complainant has stated that her husband had taken a policy no.287613341 for Rs.

500000/- under T-T 149-16. Unfortunately he was murdered on 23.08.2017.Basic sum assured

under the policy has been paid by L.I.C. but Death Accident benefit claim was rejected on the

ground that it is a case of Intentional killing which is not covered under Accidental death.

Complainant has further stated that two policies were also taken by her husband from Future

Genererali India Life Insurance Company and she got the claim under those policies. Complainant

had also appealed before ZCDRC KANPUR .They had also upheld the decision of repudiation.

Being aggrieved, the complainant approached this forum for the redressal of her grievance.

Written reply/SCN:-

19. In SCN/reply dated 20.08.2018, the respondent have stated that policy no.287613341 was

issued on the life of Yashwant Singh for the sum assured of Rs. 500000/-. Claim was lodged by

Mrs. Sunita Singh Patel who is the wife of DLA. The date of death reported 23.08.2017. FIR,

Panchnama, PMR and Police charge sheet was submitted. According to enclosed papers

submitted by claimant; it was found that DLA was murdered on 23.08.2017. According to Police

Final Report, the case was intentional Killing and the accused Satyendra Kumar Yadav was facing

trail in court under section 302 IPC. Hence DAB claim under the policy was repudiated as

Intentional killing is not covered under Accidental death. Decision was further reviewed by ZCDRC

Kanpur and they have also upheld the decision.




Pag

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Findings:-

22. Undisputedly Yashwant Singh was insured with the respondent. He was murdered in the night

of 23.08.2017. First information report was lodged by his elder brother Prem Narayan Singh

against unknown persons at case crime no. 2697 of 17 Police Station, Kotwali, District Ghazipur.

After investigation charge sheet was submitted by Investigating Officer against by Satyandra


Kumar Yadav Alias Babuya under section 302 IPC. Death benefits claim to a tune of Rs.

619347/- were paid by the respondent to the nominee. Now she has complained that accidental

death benefit not have been paid to her. Same were refused on the ground that it was a case of

intentional killing and not accidental death. In the postmortem report incised wound coupled with

contusion were found as Antemortem injuries on the body of deceased. It is not a case wherein

deceased died in some accident rather he was murdered and the trial is pending before the

Competent Court. Even in the FIR lodged by elder brother of the deceased, it is stated that

deceased wife, who is a complainant before me, has informed that somebody has killed her

husband Yashwant Singh. In such circumstances it cannot be held at this stage that the claim

has been wrongly declined by the respondent rather material available on record shows that it

was not a accident rather a murder. Accordingly complaint lacks merits and is liable to be

dismissed.

Order:-





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Mrs. Asha Devi……………….……..……....……………………………………. Complainant

V/S

Life Ins. Corp. of India ………………..……………………………………………Respondent


1. Name & Address of the Complainant Mrs. Asha Devi

Noorwas, Tikaitnagar,

Distt. Barabanki

2. Policy No:

Type of Policy


275210932

Jeevan Saral

28.09.2011







6. Reason for repudiation/Rejection Not opted







2017


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a) For the Complainant Mrs. Asha Devi




17. Mrs. Asha Devi (Complainant) has filed a complaint against Life Ins. Corp. of India


MS



18. Mrs. Asha Devi has filed a complaint on 22.02.2019 before this forum alleging that the DAB

claim of his husband`s policy was not paid by the insurance company. As per complainant the

said policy was issued on the life of her husband Late Shiv Sharan Mourya who died on

05.01.2015 in a road accident in Saudi Arabia. The complainant has stated that she has

submitted all DAB claim paper and DAB amount was paid in her account on 04.08.2017 but

suddenly withdrawn on 15.12.2017 by LIC. She approached the RIC for DAB payment but they

rejected her claim stating that deceased life assured had not opted/ applied for DAB and

premium charged for DAB was refunded by them. Being aggrieved, the complainant

approached this forum for payment of DAB claim and redressal of her grievance.

Written reply/SCN:-

19. In their SCN/reply, the respondent has stated that the Corporation was in receipt of DAB

claim under the policy along with relevant documents. The respondent has stated that in

proposal form DLA mentioned “Not Required” in the column of DAB so premium of DAB was

refunded to the claimant as decided by divisional standing committee and the claimant was

informed accordingly.

20. The complainant has filed a complaint letter, Ann VIA and correspondence with respondent


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Findings:-

22. It is typical case wherein the deceased life assured was Shiv Sharan Maurya who had taken

the insurance policy with sum assured of Rs. 312500/-. He died on 05.01.2015 in road accident.

The claim benefits along with accident claim benefits were paid by the respondents but before it

could be withdrawn by the nominee accident claim benefits were withheld and withdrawn by the

respondent on the ground that in the proposal form it is mentioned that the insured did not want

to take accident claim benefit. Feeling aggrieved complainant moved to this forum.


23. It is admitted that in response to proposal form policy bond was issued by the respondent

wherein Rs. 312.50 were deducted as premium for accident benefit. This premium was

continuously received by the respondents from the date of commencement of the policy till the

date of death of the life assured. Now the question to be looked into is as to whether it can be

accepted that the life assured was not covered under accident benefit assurance?

24. Admittedly in the proposal form accident benefit were not taken by the insured and the

relevant column it is mentioned that “NR”. Policy bond was prepared and issued wherein

amount of Rs. 312.50 was being received by the respondent as premium for accident benefits.

When the proposal form was submitted and premium for accident claim are claimed and

received by the insurance company it means that a counter proposal was given by the

respondent insurance company to the life assured which in turn was accepted by the

complainant by way of making the payment of annual premium continuously. Hence a valid

contract was entered between the insurers and insured. This valid contract was with regard to

accident benefits. When a valid contract exists between insurer and insured now the insurer

cannot deny its liability. Insurer has to honour the contract as well as its own policy bond.

Insurer has also deposited the amount accident claim benefit in the complainant‟s account

which was subsequently withheld and withdrawn by the insurer. In the circumstances I am of the

view that the complainant is entitled for the accident benefit for the death of her husband life

assured subject to rules and terms and conditions of the policy bond.

Order:-

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25. Complainant is allowed. Complainant is entitled for accident benefit claim of life assured.

Respondent shall make the payment from the date of making the claim till the date of actual

payment with the interest of 8 percent per annum within 30 days.




PROCEEDINGS BEFORE

THE INSURANCE OMBUDSMAN, STATE OF WESTERN U.P. AND UTTARAKHAND

UNDER INSURANCE OMBUDSMAN RULE 2017

OMBUDSMAN – SRI C.S. PRASAD

CASE OF MR. VIPIN KASHYAP V/S INDIA FIRST LIFE INSURANCE COMPANY

COMPLAINT REF: NO: NOI-L-024-1920-0471

AWARD NO:


Complainant

Mr. Vipin Kashyap

397, Biharipur, Memraan,

Bareilly, U.P. 243003

2. Policy No:

Type of Policy


G0000591

Loan account no.07440600047278



Mr Munna Lal

Mr Munna Lal

4. Name of the insurer India First Life Insurance Company

5. Date of Repudiation 13/3/2019

6. Reason for repudiation Non-disclosure of PED

7. Date of receipt of the 17/10/2019

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Complaint

8. Nature of complaint Repudiation

9. Amount of Claim Rs. 1752621/-


11. Amount of relief sought Rs. 1752621/-


Rule no: 13 of Insurance

Ombudsman Rules 2017

13 I (d)

13. Date of hearing/place 7/2/2020 / NOIDA


s) For the Complainant Mr. Vipin Kashyap

t) For the insurer Sri Prashant Saini



17) Brief Facts of the Case: This is a complaint filed by Mr. Vipin Kashyap against the decision

of India First Life Insurance Company Limited relating to repudiation of death claim of his father

Late Sri Munna Lal under Group Term Insurance Master Policy no. G0000591.

18). Cause of Complaint: Repudiation of death claim by the Insurance Company

a. Complainant’s arguments: The complainant stated that his father was the employee of

Bank of Baroda and the bank is also one of the promoters of the India First Life

Insurance Company. He had taken a loan under Group Credit Plan with Loan account

number 07440600047278 from the bank and consequently was the member of Group

Term Insurance under Master Policy No. G 0000591 with membership number 02241.

The insurance company issued the policy to his father after completion of proper health

check up and all other formalities. However, the insurance company has repudiated the

death claim of his father. The complainant finally approached Insurance Ombudsman for


b. Insurers’ argument: While taking the policy the life insured had applied for India First

Group Credit Life Plan and submitted duly filled and signed application cum health

declaration form along with the relevant documents and initial premium. Further, he also

signed a declaration in the application that he understood and agreed with the

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statements made in the health declaration form and those were true and complete. The

insured agreed that if any statement was found to be untrue or inaccurate or if any of the

material fact to the proposal is not disclosed, the company may declare the contract to

be null and void as per the provisions of the contract. The insurance company issued the

policy on 8/5/2018 to the insured on the basis of submitted documents and granted loan

to him. The insured expired on 4/11/2018 i.e. within six months from the inception of the

policy. It was found that the insured was suffering from Coronary Artery Disease with

diabetes and was under treatment for the same prior to his proposal for insurance and

gave false replies in the health declaration form. The insurance company repudiated the

claim for non-disclosure of material information at the time of taking insurance.

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

20) The following documents were placed for perusal:

a) Complainant letter

b) Copy of policy bond

c) SCN

21) Result of hearing with both the parties: Both the parties were present during the hearing

and reiterated their submissions. The complainant was aggrieved due to non-settlement of

death claim in respect of his father Late Sri Munna Lal who was insured under Group Credit Life

Plan of the respondent Insurance Company.

The respondent company justified the repudiation of death claim by taking recourse to section

45 of the Insurance act 1938. The said section authorizes the Insurance Company to declare

the contract of Insurance null and void, if the company finds any statement of the insured as

untrue, inaccurate or if any material fact is not disclosed at the time of signing the insurance

proposal. In their support, the Insurance Company submitted the copy of the declaration of good

health signed by Late Sri Munna Lal wherein, the deceased had declared himself to be fit and

not undertaking any treatment in recent past. The said declaration also contains the wordings

“Non-disclosure or misrepresentation of fact will highly impact the claim settlement.” The

company also produced documentary evidence in form of treatment taken by the deceased

insured from the Dhanvantari Tomar Hospital, Bareilly from 22/2/2017 to 28/2/2017 nearly 15

Pag

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months before taking the policy. The insured had also availed the Mediclaim reimbursement of

Rs.46840/- for the same, which proves that the deceased was in the knowledge of his illness,

yet he chose not to disclose it in the health declaration.

It is observed from the available records and the submissions made by both the parties, that the

insurance company had paid death claim amounting to Rs. 21,10,116/- under three other

policies, which were issued prior to February 2017 on the life of deceased insured. Regarding

the subject policy, the insurance company has acted as per the provisions of the contract and

section 45 of the Insurance act 1938 while repudiating the claim on the grounds of mis-

representation which was duly proved by documentary evidence. Also, acting as per the

provisions of Section 45, the respondent company has already refunded the premium amount of

Rs.1,17,015/-to the nominee under the policy. I see no reason to interfere with the decision of

the Insurance Company.

Place: Noida. C.S. PRASAD

Dated: 24.02.2020 INSURANCE OMBUDSMAN

(WESTERN U.P. & UTTARAKHAND)

AWARD

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

made by both the parties I see no reason to interfere with the decision of the

Insurance Company. The complaint is dismissed.

The complainant is disposed accordingly.

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PROCEEDINGS BEFORE


UNDER INSURANCE OMBUDSMAN RULE 2017

OMBUDSMAN – SRI C.S. PRASAD

MS. NOOR JAHAN BEGUM V/S INDIA FIRST LIFE INSURANCE COMPANY


AWARD NO:


Complainant

Ms. Noor Jahan Begum

w/o Late Sri Savir Khan

Bilsi,Sarah Baghauli, ,

Badayun, U.P. 243633

2. Policy No:

Type of Policy


70674617

India First Maha Jeevan Plan

17 years



Mr Savir Khan

Mr Savir Khan

4. Name of the insurer India First Life Insurance Company

5. Date of Repudiation 14/3/2019

6. Reason for repudiation Death before proposal

7. Date of receipt of the

Complaint

7/11/2019


9. Amount of Claim Rs. 500000/-


11. Amount of relief sought Rs. 500000/-


Rule no: 13 of Insurance

Ombudsman Rules 2017

13 I (d)

13. Date of hearing/place 7/2/2020 / NOIDA


u) For the Complainant Ms. Noor Jahan

v) For the insurer Sri Prashant Saini



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17) Brief Facts of the Case: This is a complaint filed by Ms. Noor Jahan Begum against the

decision of India First Life Insurance Company Limited relating to repudiation of death claim of

her husband Late Sri Savir Khan under policy no. 70674617

18). Cause of Complaint: Repudiation of death claim by the Insurance Company

Complainant’s arguments: The complainant stated that her husband had taken a life

insurance policy for a sum insured of Rs. 500000/- on 4.5.2018 from the above company

with yearly premium of Rs.25425/-. Her husband expired on 23.6.2018 and she submitted

the claim documents to the company for settlement of death claim. During investigation the

officer had collected the documents and demanded a bribe of Rs.20000/- for favourable

consideration. The complainant refused for it. The insurance company repudiated the death

claim of her spouse on flimsy grounds. The complainant finally approached Insurance

Ombudsman for redressal of her grievance.

Insurers’ argument: The insurance company stated in their SCN that the complainant had

submitted the documents for settlement of death claim of her husband. During the course of

investigation, it came to the knowledge of the company that the insured had expired on

1/5/2018 which is prior to the signing of the proposal form dated 3/5/2018. The company

after perusing the relevant documents procured during investigations, i.e. statement of the

Gram Pradhan of the village Mrs. Sarvesh (Mobile no. 9761919287) along with the copy of

the parivar register maintained at the village level in this respect, came to the conclusion

that some third person had managed to avail the death certificate by manipulation and

fraudulent means as the purported policy holder had already died prior to the issuance of

the subject policy. Therefore, the company had repudiated the death claim.


20) The following documents were placed for perusal:

a) Complainant letter

b) Copy of policy bond

c) SCN

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21) Observations & Conclusions : Both the parties were present during the hearing and

reiterated their submissions. The complainant is aggrieved due to non-settlement of death claim

in respect of her husband Late Sri Savir Khan.

The respondent company tried to justify the repudiation of death claim by placing reliance to the

various documents submitted by the investigating agency and its report.

It is observed from the available records and the submissions made by both the parties, that the

insurance company has based its repudiation decision mainly on the basis of investigating

report which suffers from serious flaws. The investigation report has shown the deceased as

farmer whereas the complainant informed during hearing that he was a mechanic. The

investigation report has shown the income of the deceased as yearly Rs.100000/- whereas the

proposal papers indicate Rs.240000/-. As regards, date of death, the investigation report relies

on the statement given by the Gram Pradhan of the village which mentions the date of death as

1.5.2018. On the other hand, in the investigation summary, it mentions that the burial was done

on 24.06.2018. It seems that the investigator and the insurance company conveniently relied

selectively on those observations which favored their decision of repudiation and ignored more

credible documents issued by the government authorities. Interestingly, the policy procuring

agent in this case is the Bank of Baroda who is the banker of the deceased and completed the

documentation at the time of proposal. The complainant also submitted a statement of the same

Gram Pradhan mentioning the date of death of the deceased as 23.6.2018 which is consistent

with the Death Certificate issued by the competent authority of the state government and the

date of burial. The insurance company could not adduce evidence to question the Death

Certificate issued by the state government. I find that the action of repudiation of claim by the

Insurance Company is arbitrary and unjustified, and therefore is set aside.

AWARD


by both the parties Insurance Company is directed to settle the Death Claim as per

terms and conditions of the policy.

The complainant is disposed accordingly.

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

provisions of Insurance Ombudsman Rules, 2017:

a) According to Rule 17(6) of Insurance Ombudsman Rules,2017, the insurer shall comply with

the award within thirty days of the receipt of the award and intimate compliance of the same to

the Ombudsman.




PROCEEDINGS BEFORE


UNDER INSURANCE OMBUDSMAN RULES 2017

OMBUDSMAN – SH. C.S.PRASAD

CASE OF ST. SUNMAN V/S LIFE INSURANCE CORPORATION OF INDIA


AWARD NO:


Complainant

Smt. Suman

B 174, Defence Garden Colony

Partapur, Meerut-250103

2. Policy No:

Type of Policy


2095400566

Life Plan

17/14



Late Sh. Anand Kumar

Late Sh. Anand Kumar




Non-Disclosure of Material Fact of

Illness

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9. Amount of Claim Rs. 20 Lakh


11. Amount of relief sought Rs.20 Lakh


IOB rules

13 (1) (b)

13. Date of hearing/place On 24.12.2019 and on 18.12.2020 at

Noida


w) For the Complainant Absent on Both days

x) For the insurer Sh. Arvind Kumar Tyagi, Ao



1) Smt. Suman( Complainant) had filed a complaint against decision of Life Insurance

Corporation of India ( respondent) alleging Repudiation of Death Claim under the policy no.

2095400566.

2) The personal hearing in the case was fixed on24.12.2020 and on18.2.2020. The

complainant did not attend the hearing on both days and none represented her. However,

insurer was present on both days. Hence the case is dismissed in default without going into

merits of the case.

3) Copies of the order to both the parties.




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PROCEEDINGS BEFORE




CASE OF SMT. SUMAN V/S LIFE INSURANCE CORPORATION OF INDIA


AWARD NO:


Complainant

Smt. Suman W/O Late Rampal

R/O Mohalla Giljai

Shahbad, Hardoi

Uttar Pradesh-241124

2. Policy No:

Type of Policy


221435907 & 227382413

Life Plan Life Plan



Late Sh. Rampal

Late Sh. Ram Pal



6. Reason for repudiation Premium due on 4/2017 and 7/2017 not

received


8. Nature of complaint Non-Settlement of Death Claim

9. Amount of Claim Rs.1.15 Lakh & Rs.2 Lakh


11. Amount of relief sought Rs.3.15 Lakh


IOB rules

13 (1) (b)

13. Date of hearing/place On 24.12.2019 and on 18.2.2020 at

Noida


y) For the Complainant Absent on both days

z) For the insurer Sh. Gangadhar & Sh. Sumit Kumar



1) Smt. Suman( Complainant) had filed a complaint against decision of Life Insurance

Corporation of India ( respondent) alleging Repudiation of Death Claim under the policy no.

221435907 and 227382413.

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complainant did not attend the hearing on both days and none represented her. However

insurer was present on both days. Hence the case is dismissed in default without going into its

merits.

3)Copies of the order to both the parties.




PROCEEDINGS BEFORE




CASE OF SH. G.P.BAHUKHANDI V/S LIFE INSURANCE CORPORATION OF INDIA


AWARD NO:


Complainant

Sh. G.P. Bahukhandi

Upper Kalabarh, P.O. Kotdwara

Pauri Garhwal, Uttarakhand-246149

2. Policy No:

Type of Policy


271737720

Life Plan



Late Sh. Jagdamba Prasad

Late Sh. Jagdamba Prasad


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NA



9. Amount of Claim Rs.


11. Amount of relief sought Rs.


IOB rules

13.1.b

13. Date of hearing/place On 24.12.2019 and 18.2.2020 at Noida


aa) For the Complainant Absent on both days

bb) For the insurer Sh. Yashvardhan Bisht, AO

15 Complaint how disposed Settled


17)Brief Facts of case ;- This complaint is filed by Sh. G.P. Bahukhandi against Life Insurance

Corporation of India relating to non-settlement of death claim under policy no. 271737720

issued on the life of Sh. Jagdamba Prasad.

18)Cause of Complaint:- Non- Settlement of death claim under the Policy

a) Complainants argument :- The complainant stated that his nephew Sh. Jagdamba Prasad

had taken a policy no. 271737720 from Life Insurance Corporation of India on 6.2.2010 on

single premium of Rs.60,000/-. His nephew died on 27.3.2019at his residence . Smt. Kadambari

Devi who is the legal nominee of the deceased had submitted all relevant documents to the

insurer in April-2019. The insurer has not made the payment of death claim till date.

b) Insurers’ argument:- The insurer stated that Death Claim payment of Rs.1,01,112/-has

been made under the policy on 25.7.2019 in the bank account of the nominee, St. Kadambari

Devi through NEFT.


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a) Complaint Letter

b) Repudiation Letter

c) Policy Document

d) SCN

21) Observations and Conclusion ;-Personal hearing of the case was held on 24.12.2019

and 18.2.2020 . The complainant was absent on both days . The insurer attended the

hearing on 18.2.2020. The complainant has sent a letter dated03.2.2020, stating his inability

to attend the hearing due to his illness. He had nothing to add apart from his written

complaint. The insurer submitted that death claim payment of Rs.1,01,112/- has been made

on 25.7.2019 through NEFT vide UTR No. CMS118444437 and beneficiary account has

been credited on 26.7.2019. In view of above fact the complainant is dismissed as the

grievance has been redressed.




AWARD


made by the insurer during the course of hearing, the complaint is dismissed as

the grievance has been redressed.

The complaint is disposed off accordingly.

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PROCEEDINGS BEFORE




CASE OF SMT. VIMLA DEVI V/S LIFE INSURANCE CORPORATION OF INDIA


AWARD NO:


Complainant

Smt. Vimla Devi

W/O Sh. Ram Rakha Singh

Village- Peli Chouhan, Post Jamna

Khas

Amroha, Uttar Pradesh-244501

2. Policy No:

Type of Policy


243419448

Life Plan



Smt. Nirmal Chouhan

Smt. Nirmal Chouhan



6. Reason for repudiation Non Disclosure of Material fact of

Illness


8. Nature of complaint Repudiation of Death claim

9. Amount of Claim Rs.5 lakh


11. Amount of relief sought Rs.5 lakh


IOB rules

13.1.b

13. Date of hearing/place On 18.2.2020 at Noida


cc) For the Complainant St. Vimla Devi, Self

dd) For the insurer Ms.Upma Sethi,AO



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17)Brief Facts of case ;- This complaint is filed by Smt. Vimla Devi against the decision of Life

Insurance Corporation of India relating to repudiation of death claim under policy number

243419448 issued on the life of her daughter Late Smt. Nirmal Chouhan.

18)Cause of Complaint:- Repudiation of death claim under the policy.

Complainants argument :- The complainant stated that her daughter had taken a policy

number 243419448 from LICI, Branch Lohagat, Distt. Champawat, Uttarakhand on 14.3.2016.

She submitted that her daughter died on 8.12.2016suddenly at home due to headache. Her

daughter was hale and hearty before taking the policy. The complainant had submitted all the

claim forms to the insurer for settlement of death claim, The insurer repudiated death claim

payment vide their letter dated 2.7.2019 on the ground of non-disclosure of material facts of

previous illness.

Insurers’ argument:- The insurer stated that a policy number 243419448 was issued on the

life of Late Smt. Nirmal Chouhan on 14.3.2016 on half yearly mode of premium of Rs.11528/-for

sum assured of Rs.5 lakh. The insurer received death intimation of the life assured and date of

death was 8.12.2016 i.e. life assured died within 8 months and 24 days of inception of policy.

On investigation it was found that she was suffering from „Mixed Cephalalgia more than 5 years

with migraine. This fact was proved through the prescription dated 11.2.2016 of Dr. Tarun

Agarwal, Neuro care Clinic, Moradabad. The DLA deliberately did not disclose the material fact

regarding her previous illness at the time of submission of proposal. This non disclosure

amounted to misrepresentation. Hence the death claim payment was repudiated by the SDM,

Haldwani and this decision was upheld by the Zonal Claims Dispute Redressal Commitee,

Kanpur also.



a) Complaint Letter


c) Policy Document

d) SCN

21) Observations and Conclusion;-Personal hearing in the case was fixed on 13.12.2019.

Both the complainant and insurer attended the hearing and reiterated their submissions. The

complainant stated that her daughter died suddenly at home due to head ache.The insurer

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submitted that life assued died with in 9 months of inception of policy and the DLA was

suffering from “Mixed Cephalagia for more than 5 years with migrane. This material fact of

her previous illness was not disclosed at the time of taking the policy.

It is observed that the policy was issued on the life of deceased at the age of 22 years on

14.3.2016. The immediate cause of death was severe Head Ache. The MRI study of brain

by Amit MRI Centre, Moradabad dated 11.2.2016 shows “Normal Brain Scan”. The insurer‟s

contention in their SCN dated 12.11.2019 that “ if she had disclosed her illness in the

proposal form , our decision of underwriting would have been affected”, stands defeated in

the light of normal MRI report dated 11.2.2016. The investigating officer has also not

mentioned any adverse remark in his report. The insurer has not given any evidence

regarding illness prior to inception of policy nor have they produced any evidence to prove

mensrea. Keeping in view above facts insurer is directed to make payment of death claim

under the policy.





the Ombudsman.




AWARD


by both the parties during the course of hearing, the Insurance company is directed to

make payment of death claim under the policy.


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PROCEEDINGS BEFORE




CASE OF SH. ARJUN SHARMA V/S LIFE INSURANCE CORPORATION OF INDIA



Complainant

Sh. Arjun Sharma

S/OLate Sh.Santosh Kumar

Sharma,Mohalla-Sotiyan, Near Dr. Soti

Bijnor, Uttar Pradesh-246701

2. Policy No:

Type of Policy


258399449

Life Plan

17/17



Late Sh. Santosh Kumar Sharma

Late Sh. Santosh Kumar Sharma




Non Disclosure of Previous illness



9. Amount of Claim Rs.2 Lakh




IOB rules

13.1.b



ee) For the Complainant Sh. Arjun Sharma, self

ff) For the insurer Sh. Arvind Kumar Tyagi, AO



17)Brief Facts of case ;- This complaint is filed by Sh. Arjun Sharma against the decision of

Life Insurance Corporation of India relating to Repudiation of Death Claim under policy number

issued on the life of 258399449 issued on the life of his late father Sh. Santosh Kumar Sharma.

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18)Cause of Complaint:- Repudiation of Death Claim under the policy.

Complainants argument ;- The complainant stated that his father had taken a policy from LICI

on 23.5.2016 for sum assured of Rs.2 Lakh. He stated that his father was having swelling in the

neck for last 1 year and after some time it became cancerous and his father died on

7.9.2018.The complainant had submitted all the relevant claim documents to the insurer. The

insurer repudiated the death claim payment on the ground of non-disclosure of previous illness.

Insurers’ argument:-The insurer stated that a policy number 258399449 was issued on the life

of Sh. Santosh Kumar Sharma on 23.5.2016 with plan & term 827-17 for 2 lakh sum assured.

The life assured died on 7.9.2018 i.e. after 2 year 3 months14days. The complainant was

suffering from Carcinoma base of Tongue( Metastatic lymph node CA) at that time. This fact

was duly proved through treatment papers31.5.2016& 15.7.2016 of Nehru Hospital

Postgraduate Institute of Medical Education and Research , Chandigarh. As per discharge

summary issued by AIIMS Rishikesh , the DLA was having history of Beedi smoking for 25

years and tobacco chewing for 5 years. The DLA did not disclose the material fact regarding his

previous illness at the time of proposal. This non disclosure amounted to fraud. Hence death

claim payment was repudiated by SDM, Meerut and this decision was upheld by Zonal Claim

Dispute Redressal Commitee, Kanpur.



a) Complaint Letter


c) Policy Document

d) SCN

21) Observations and Conclusion;- Personal hearing in the case was fixed on 18.2.2020.

Both the complainant and insurer attended the hearing and reiterated their submissions.The

insurer submitted that the DLA was having history of Beedi smoking for last 25 years and

tobacco chewing for 5 years . This was not disclosed at the time of filling of proposal .

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It is observed that the policy was issued on the life of DLA on 23.5.2016 at the age of 53

years on the basis of Medical Report, found in order by the insurer. The treatment papers

submitted by insurer are after the issuance of policy i. e. first time lymph node was

diagnosed on 5.10.2016.The insurer has not submitted any document/ treatment paper prior

to the issuance of policy.

The insurer has failed to produce credible evidence to prove that the DLA was suffering

from cancer before the inception of the policy, and that it was in the knowledge of deceased

and this information was deliberately concealed by deceased. Having failed to prove

mensrea on the part of the deceased life assured , the insurance company is directed to






the Ombudsman.




AWARD


made by both the parties during the course of hearing, the insurance company is

directed to make payment of death claim under the policy.


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PROCEEDINGS BEFORE




CASE OF SH. KUNWAR PAL SINGH V/S LIFE INSURANCE CORPORATION OF INDIA


AWARD NO:


Complainant

Sh.Kunwar Pal Singh

Village & Post- Birauli

BulandShahar, Uttar Pradesh-202390

2. Policy No:

Type of Policy


900100032

Life plan



Late Rukmani Devi

Late Rukmani devi




Mis-Statement of age in Membership

Form



9. Amount of Claim Rs.


11. Amount of relief sought RS.


IOB rules

13.1.b



gg) For the Complainant Sh. Kunwar Pal Singh, Self

hh) For the insurer Absent



17)Brief Facts of case ;- This complaint is filed by Sh. Kunwar Pal Singh against the decision

of LIC of India relating to rejection of death claim under Master policy no. 900100032 issued on

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the life of his wife Late Smt. Rukmani Devi through Allahbad Bank a/c no. 50095762976under

Pradhan Mantri Jeevan Jyoti Scheme on 19.8.2015.

18)Cause of Complaint:- Repudiation of Death Claim under the policy.

Complainants argument;- The complainant stated that a policy was issued on the life of his

wife Late Smt. Rukmani Devi under Pradhan Mantri Jeevan Jyoti Yojna, through Allahbad

Bank, Birauli branch , Account no. 50095762976 on 19.8.2015. The policy was issued on the

basis of copy of Aadhar Card. The complainant stated that his wife died due to Cancer

on4.3.2018 at AIIMS, Delhi.The complainant had submitted all the claim forms to the insurer for

the payment of death claim. The death claim payment had been rejected by the insurer vide

their letter dated 12.4.2019.

Insurers’ argument:- The insurer stated that Smt. Munni Devi was covered under Pradhan

Mantri Jeevan Jyoti Yojna, through Allahbad Bank, Birauli branch account no 50095762976 on

19.8.2015. The insurer had received all claim forms for death claim payment from the

complainant. On scrutiny of claim forms it was found that at the inception of policy , age of the

deceased life assured was more than 50 years. As per terms and conditions of PMJJBY

scheme, member‟s age should from 18 years to 50 years at the time of joining the scheme,

whereas in this case , age of the DLA was 63 years 7 months and hence she was not eligible

for the benefits under the scheme.



a) Complaint Letter


c) Policy Document

d) SCN

21)Observations and Conclusion;- Personal hearing in the case was held on 18.2.2020 .

The complainant was present. The insurer was absent in the hearing without any intimation.

The complainant submitted that her wife i.e. insured died and the insurer rejected death claim

payment on the ground that the deceased life assured was not eligible for the scheme.

It is observed that the policy was issued on the basis of the Aadhar Card of the insured. If the

insured was not eligible, then why was she issued the policy which they should have? Both the

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Insurance company and Allahabad Bank did not verify the age at the time of inclusion of the

insured in the master policy. Further, the premium amount was deducted from the bank account

of the deceased life assured regularly. In view of these facts, insurance company is directed to






the Ombudsman.




AWARD


by the complainant during the course of hearing, the insurance company is directed to



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PROCEEDINGS BEFORE




CASE OF RAJNI KUMARI V/S LIFE INSURANCE CORPORATION OF INDIA


AWARD NO:


Complainant

Sh. Rajni Kumari D/O Swarn singh

R/O -434, Ambedkar Colony, Chawni

Aligarh, Uttar Pradesh

2. Policy No:

Type of Policy


565523043

Life Plan



Late Sh. Devendra Kumar

Late Sh. Devendra Kumar




Non-Disclosure of material facts of his

habit of alcohol intake







IOB rules

13.1.b



ii) For the Complainant Ms. Rajni Kumari, Self

jj) For the insurer Sh. S.C. Rajoria, AAO



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17)Brief Facts of case ;-

This complaint is filed by Smt. Rajni Kumari against the decision of Life Insurance Corporation

of India relating to repudiation of death claim under policy number 565523043 issued on the life

of her brother Late Sh. Devendra Kumar.

18)Cause of Complaint:- Repudiation of death claim under the policy.

Complainants argument ;- The complainant stated that her brother had taken a policy from

Life Insurance Corporation of India for sum assured of Rs.5 Lakh on 9.1.2018on half yearly

mode of payment of Rs.15288/- with polity term of 19 year and premium paying term of 16

years. The complainant stated that her brother was missing from 28.9.2018. On 1.10.22018

they received information from the police about unknown dead body, which was his brother‟s.

At per postmortem Report cause of death was Antimortem Injury.. The complainant had

submitted all the relevant claim forms to the insurer for death claim payment. . The death claim

payment was repudiated by the insurer vide their letter dated 18.6.2019 stating the death due

to drowning in the canal after consumption of alcohol.

Insurers’ argument:- The insurer stated that a policy named “ Jeevan Lakshya having no.

565523043 was issued on the on the life of Sh. Devendra Kumar on 9.1.2018. The insurer

received intimation of death of the life assured along with claim forms for settlement of claim.

The DLA deliberately did not disclose the material fact regarding his habit of alcohol intake at

the time of proposal. This non disclosure amounted to misrepresentation. The DLA died due to

drowning in canal after consumption of alcohol. This fact is duly proved through the written

statement given by the mother of the deceased and co –signed by his sister( nominee) in the

policy to police authorities. Hence death claim was repudiated by SDM, Aligarh and this

decision was upheld by ZCDRC, Kanpur also


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a) Complaint Letter


c) Policy Document

d) SCN

21) Observations and Conclusion:- Personal hearing in the case was fixed on 13.12.2019.


insurer submitted that the DLA did not disclose the material fact regarding his habit of

alcohol intake at the time of proposal. This non disclosure amounted to misrepresentation.

The DLA died due to drowning in canal after consumption of alcohol. This fact is duly proved

through the written statement given by the mother of the deceased and co –signed by his

sister( nominee) in the policy to police authorities. The complainant submitted that her

mother is illiterate and has not given any written statement to police authorities.

It is observed that as per Post Mortem Report, death was due to Comma and Asphyxia as a

result of anti mortem injury& drowning. Since the gut / abdomen of the insured was eaten by

the animals, the post mortem report does not indicate presence of alcohol in the deceased‟s

body. In the absence of critical evidence it can not be said with certitude that the insured

died of drowning as a result of alcohol consumption. The post mortem report itself

concluded that the cause of death is uncertain. While the police report as signed by the

insured‟s mother states that the deceased was in the habit of taking alcohol, there are three

affidavits of deceased‟s neighbor‟s on record which vouch that the insured was never seen

taking intoxicating materials. Even the investigation report conducted by the insurer states

that health and habits of the DLA were good.

The only evidence, which has been invoked by the insurance company to repudiate the

claim is the insured‟s mother‟s letter to the police in which it is written that her son was used

to taking alcohol. Given the fact that the mother is illiterate and considering the tone and

tenor of the letter, a prudent mind can reasonably assume that it has been written by the

police themselves to close the case. The complainant has alleged in her affidavit that the

police had taken the thumb impression of her mother on a blank paper.

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The insurer failed to prove that the deceased had consumed alcohol. As per post mortem

report ,the vital parts of abdomen were missing, probably eaten by animals In the absence

of any clear proof presumption of alcoholism by the insurer is not justified. The insurer is

directed to make payment of death claim under the policy.





the Ombudsman.




AWARD


made by both the parties during the course of hearing, the insurer is directed to

make death claim payment under the policy.


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PROCEEDINGS BEFORE



OMBUDSMAN – SH. C.S. PRASAD

CASE OF SUNITA DEVI V/S LIFE INSURANCE CORPORATION OF INDIA



Complainant

Smt. Sunita Devi

W/O Sh. Sohan Pal, Village- Banjarpur

P.O. Bilaspur, Gautam Budh Nagar


2. Policy No:

Type of Policy


564667969

Life Plan

20 Years



Late Manindra Kumar

Late Maninder Kumar




Difference in the name of the deceased

as per death certificate


8. Nature of complaint Non-Settlement of death claim

9. Amount of Claim Rs.1.25 Lakh


11. Amount of relief sought Rs.1.25 Lakh


IOB rules

13 (1) (b)

13. Date of hearing/place 24.12.2019 and on 18.2.2020 at Noida


kk) For the Complainant Absent

ll) For the insurer Sh.Satish Chandra Rajoria, AAO



17)Brief Facts of case ;-This complaint is filed by St. Sunita Devi against the decision of LIC of

India relating to non-settlement of death claim under policy no. 564667969 issued on the life of

her son Late Manindra Kumar.

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18)Cause of Complaint:- Non Settlement of Death Claim under the Policy.

Complainants argument :- The complainant stated that her son had taken a policy no.

564667969 from LIC of India on 26.7.2013 . Her son died on 8.8.2019 due to accident. The

complainant had submitted all the relevant claim forms 5.9.2019 to the insurer for settlement

of death claim. The insurer has not settled death clim till date due to difference in name of the

deceased in the death certificate.

Insurers’ argument:- The insurer in their SCN dated 14.10.2019 stated that policy number

564667969 was issued on the life of Late Sh. Manindra Kumar S/O Sonpal, at the age of 21

years. The life assured died on 8.8.2019. The complainant has submitted intimation of death of

the life assured alongwith all claim form and death certificate in the name of Munendra Kumar

S/O Sh. Sohan Pal instead of Maninder Kumar S/O Son Pal. The insurer had conveyed this to

the complainant and requested her to produce the death certificate and FIR after getting

correction in the name of deceased and his father for early settlement of claim.



a) Complaint Letter


c) Policy Document

d) SCN

21) Observations and Conclusion:- Personal hearing in the case was held on 24.12.2019

and on 18.2.2020 . The complainant was absent on both days but the insurer attended

the hearing on both days. The insurer submitted that the death claim of basic sum assured

has been paid . The insurer has written to the complainant on 11.11.2019, on 26.12.2019,

on 28.1.2020 and on 12.2.2020 to submit attested copy of FIR, Post mortem report,

Panchnama, FIR charge sheet to enable to settle accidental death claim benefit under the

policy. In view of discrepancy in the death certificate, the insurer is justified in asking for the

documents to establish the bonafide of the claim.

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It is observed that settlement of accidental death claim benefit is pending due to non

submission of requirements by the complainant. In view of above, the insurer is directed to

settle accidental death claim benefit upon receipt of requirements from the complainant

within a reasonable time.





the Ombudsman.




AWARD


by the insurer during the course of hearing, the insurer is directed to settle accidental

benefit claim upon receipt of requirements from the complainant under the policy.


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PROCEEDINGS BEFORE




CASE OF SMT. PINKI V/S LIFE INSURANCE CORPORATION OF INDIA


AWARD NO:


Complainant

Smt. Pinki, W/O Late Sh. Upendra Pal

Singh

R/O Piparia Uprela, Tehsil Amla

Distt. Bareilly, Uttar Pradesh-243303

2. Policy No:

Type of Policy


223867391

Life plan

75/20

3 Name of the insured


Late Sh. Upendra Pal Singh

Late Sh. Upendra Pal Singh




Non Disclosure of Material Fact of

Previous Illness







IOB rules

13.1.b



mm) For the Complainant Smt.Pinki Devi, Self

nn) For the insurer Sh. Sunit Kumar, AO



17)Brief Facts of case ;- This complaint is filed by Smt. Pinki, against the decision of LICI

relating to Repudiation of Death Claim under policy number 223867391issued on the life of

her husband Late Sh. Upendra Pal Singh.

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18)Cause of Complaint:- Repudiation of Death Claim under policy.

a)Complainants argument ;- The complainant stated that her husband had taken a policy

number 22386739 from LICI on 28.1.2011. She stated that her husband had deposited all due

premiums regularly. Her husband died in 13.8.2017 due to cancer . The complainant had

deposited all the relevant claim forms to the insurer for settlement of death claim. The insurer

has repudiated the claim on 18.2.2019 on the ground of non-disclosure of previous illness.

Insurers’ argument:- The insurer stated that a policy no. 22386739 for sum assured of Rs.1

Lakh was issued on the life of Sh. Upendra Pal on 28.1.2011. The said policy was revived on

29.2.2016 on the basis of DGH dated 29.2.2016. The life assured died on 13.8.2017 due to

cancer. On investigation of claim it was found that the DLA was suffering from Mouth Cancer(

Carcinoma left side of Tongue)and was under treatment of Rajiv Gandhi Cancer Institute and

Safdarjung Hospital, New Delhi.The radiotherapy of the DLA was done for the period from

23.9.2015 to 16.11.2015 in the Rajiv Gandhi Cancer Institute and Research Centre Delhi. The

DLA received one cycle of Chemo followed by surgery. The DLA did not disclose his disease at

the time of revival of policy on 29.2.2016. This non disclosure amounted to misrepresentation.

Hence the death claim payment was repudiated by SDM Bareilly and this decision was upheld

by ZCDRC also.



a) Complaint Letter


c) Policy Document

d) SCN

21)Observations and Conclusion;- Personal hearing in the case was fixed on 18.2.2020.


complainant submitted that regular premiums were being paid to the agent by the deceased.

The agent did not deposit the premium due on 28.1.2015 and the policy got lapsed. The

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agent revived the policy on 29.2.2016. The insurer submitted that at the time of revival, the

DLA did not disclose his previous illness and due to non disclosure of material facts of

illness, death claim was repudiated.

Had the policy been renewed in time, there would not have been anybreak and the

nominee, in this case a poor and illiterate peasant women, would have got the death claim

of her husband, the insured. Therefore, the crucial question is: who was responsible-agent

or the insured-for the lapse of the policy? The complainant avers that her deceased

husband, an illiterate farmer used to hand over the premium amount to the agent for

renewal of the policy. But obviously she can not prove it and her husband is no more to give

us any clue. Yet , considering the deceased regularly paid premiums till January-2015, her

assertion can not be summarily rejected. Moreover, it is observed that the writing as well as

the signature on the DGH form do not seem to be that of the insured as is evident from his

signatures on the proposal ( below his photograph on the right upper corner). Further , that

the agent played a very dubious role in the whole episode is confirmed by the ZCDRC‟S

decision dated 15.6.2019 vide which strong disciplinary action has been recommended

against him.

However, what can not be totally ignored in the interest of justice is the fact that DLA was

suffering from Mouth Cancer( Carcinoma left side of Tongue)and was under treatment of

Rajiv Gandhi Cancer Institute and Sufdarjung Hospital, New Delhi. The radiotherapy of the

DLA was done for the period from 23.9.2015 to 16.11.2015 in the Rajiv Gandhi Cancer

Institute and Research Centre Delhi. The DLA received one cycle of Chemo followed by

surgery. This was not disclosed at the time of revival of policy on 29.2.2016.Therefore ,

insurer repudiated the claim by treating the revival null and void as per Section 45 of the

Insurance Act and made, the payment of the paid up value of the policy to the complainant.

However, considering the gross deficiency in service by the agent of the insurance

company, it would be travesty of justice to allow for the forfeiture of revival amount and

subsequent premium. The insurer is directed to refund the revival amount deposited on

29.2.2016 along with premium received by the insurer on 17.2.2017 to the complainant

along with interest.

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0





the Ombudsman.




AWARD



refund premium received on 29.2.2016 and on 17.2.2017 under the policy and

PPHI @6% from18.2.2019, the date of rejection of death claim till the date of

actual payment.

The complaint is treated as closed accordingly.

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1

PROCEEDINGS BEFORE




CASE OF ST. BALVINDER KAUR V/S MAX LIFE INSURANCE COMPANY LIMITED



Complainant

Ms. Balvinder Kaur

D/O Trilok Singh

Village –Gahaluiya, Post Navadiya

Banki Banda, Shahjahanpur , Uttar

Pradesh

Pin-244713

2. Policy No:

Type of Policy


310856117

Non-Settlement of Death Claim Life

plan

77/20



Late Sh. Jasvinder Singh

Late Sh. Jasvinder Singh

4. Name of the insurer Max Life Insurance Company Limited



Fraud/ As the Life assured is alive







IOB rules

13.1.d

13. Date of hearing/place On17.1.2020 and 6.2.2020 at Noida


oo) For the Complainant Absent on both days

pp) For the insurer Sh. Saurabh Dhingra, Manager



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2

1) Ms. Balvinder Kaur ( Complainant) had filed a complaint against decision of Max Life

Insurance Company Limited( respondent) alleging Repudiation of Death Claim under the policy

no. 310856117




merits of the case.





PROCEEDINGS BEFORE




CASE OF SMT. CHARAN KAUR V/S MAX LIFE INSURANCE COMPANY LIMITED


AWARD NO:


Complainant

Smt. Charan kaur

W/O Late Surjeet Singh

Post Office Barhanpur

Tehsil Nagina, Bijnor

Uttar Pradesh 246724

2. Policy No:

Type of Policy


138449129

Life Plan

60/20



Late Sh. Surjit Singh

Late Sh. Surjit Singh

4. Name of the insurer Max life insurance company limited


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3


Death prior to proposal


8. Nature of complaint Non Settlement of Death Claim

9. Amount of Claim Rs. 8,85,135/-




IOB rules

13 (1) (b)



qq) For the Complainant Absent on both days.

rr) For the insurer Sh. Saurabh Dhingra,Manager

15 Complaint how disposed Dismissed in Default.


1) Smt. Charan kaur(Co mplainant) had filed a complaint against decision of Max Life


no. 35002623




merits of the case.





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4

PROCEEDINGS BEFORE




CASE OF SMT. RAJNI SHARMA V/S MAX LIFE INSURANCE COMPANY LIMITED


AWARD NO:


Complainant

St. Rajni Sharma

Flat No. B-705, Paradise Apartment

Ganga nagar, Mawana Road,

Meerut, Uttar Pradesh- 250001

2. Policy No:

Type of Policy


35002623

Life Plan



Late Sh. Jugal Kishore Sharma

Axis Bank Limited

4. Name of the insurer Max Life Insurance Company Limited



Non-Disclosure of material facts of

previous illness



9. Amount of Claim Rs.11,26,288




IOB rules

13.1.d



ss) For the Complainant Absent on both days

tt) For the insurer Sh. Saurabh Dhingra, Manager



1) Smt. Rajni Sharma ( Complainant) had filed a complaint against decision of Max Life


no. 35002623

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5




merits of the case.





PROCEEDINGS BEFORE




CASE OF SH. AJAY CHOUDHARY V/S MAX LIFE INSURANCE COMPANY LIMITED


AWARD NO:


Complainant

Sh. Ajay Choudhary

26/39, Aheer pada, Raja Mandi

Agra, Uttar Pradesh - 282002

2. Policy No:

Type of Policy


277613022 and 277605697

Life plan Life Plan



Late Madhu Bharti, Sh. Ajay

Choudhary

Late Madhu Bharti, Late Madhu Bharti

4. Name of the insurer Max Life Insurance Company


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6

6. Reason for repudiation Non-Disclosure of previous illness



9. Amount of Claim Rs.3,22,265




IOB rules

13 (1) (b)

13. Date of hearing/place On 17.1.2020 and on 6.2.2020 at Noida


uu) For the Complainant Sh. Ajay Choudhary, Self

vv) For the insurer Sh. Saurabh Dhingra, Manager



17)Brief Facts of case ;- This complaint is filed by Sh. Ajay Choudhary against the decision of

Max Life Insurance Company limited relating to repudiation of death claim under policy no‟s

277613022 issued on the life of his mother Late St. Madhu Bharti.

18)Cause of Complaint:- Repudiation of death claim under the policies.

a)Complainants argument :- The complainant stated that his mother had taken 2 policies from

Max Life Insurance Company Limited in the year 2015. Both the policies were issued on the

basis of medical report of the deceased life assured. His mother died after payment of 3

instalment of premiums. The complainant had submitted all relevant claim forms to the insurer

for settlement of death claim . The insurer had repudiated payment of claim on the ground of

non-disclosure of material fact of pre-existing disease.

Insurers’ argument:- The insurer stated that 2 policies named Max Life Whole life Super 10

pay and Max Life Gain Premier bearing no‟s 277613022 and 277605697 respectively were

issued on 4.9.2015 on the life of Late Smt. Madhu Bharti and on the life of Sh. Ajay choudhary

on annual mode of payment of Rs.30,000/- each with sum assured of Rs.3.33 lakh and Rs.3

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7

lakh . The life assured Madhu Bharti died on 18.8.2017 i.e. within 2 years of inception of policy.

The death claim payment was repudiated due to concealment of her illness by the proposer at

the time filing of proposal form . The deceased had concealed the material fact that she was

suffering from Breast Cancer for 7 years before inception of the policies In view of above, the

claim was repudiated based on the incorrect and wrong disclosure vide letter dated 15.5.2019.



a) Complaint Letter


c) Policy Document

d) SCN

21) Observations and Conclusion:- );- Personal hearing in the case was held

on17.1.2020. and on 6.2.2020 . The complainant was absent on17.1.2020 but the

insurer was present. Both the parties appeared for personal hearing on 6.2.2020 and

reiterated their submissions. The complainant stated that the death claim payment on

the life of his mother had been rejected by the insurer and submitted that his mother was

working as an agent with the insurer. The insurer stated that as per written statement

dated 15.3.2017 of Dr. Deo Narendra Agra UP,DLA was suffering from Breast Cancer

for the last 7 years, which was prior to the policy issuance .It was a deliberate act of

concealment of material fact of illness.

It is observed that policy was issued on the basis of medical report which was found to be in

order by the insurer. Even from attending physician statement ( Form-C) dated 27.4.2018,

signed and stamped by Dr. Deo Narendra it is clear that the date of diagnosis and date of

first consultation was 15.3.2017 which was after issuance of policy. It is also mentioned in

the Form –C that “No treatment was taken by the deceased”.

The insurer has failed to produce credible evidence to prove that the DLA was suffering

from cancer before inception of the policy, and that it was in the knowledge of deceased and

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8

this information was deliberately concealed by deceased. Having failed to prove mens rea

on the part of the deceased life assured , the insurance company is directed to make

payment of death claim under the policy no. 277613022. In the other policy no. 277605697

the complainant himself i.e.Sh. Ajay choudhary is life assured. Therefore question of death

claim does not arise.





the Ombudsman.




AWARD



make death claim payment only under the policy no. 277613022.


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9

PROCEEDINGS BEFORE




CASE OF Ms. MUNIYA V/S PNB MET LIFE INSURANCE COMPANY LIMITED


AWARD NO:


Complainant

Smt. Muniya

Sakarthali , Salempur,

Gosain, Amroha


2. Policy No:

Type of Policy


22540881

Life Plan

30 Years



Ms. Pushpa

Ms. Pushpa

4. Name of the insurer PNB Met Life Insurance Company



Death prior to proposal


8. Nature of complaint Non-Settlement of Death claim





IOB rules

13 (1) (b)

13. Date of hearing/place On 29.1.2020 and on 6.2.2020 at Noida


ww) For the Complainant Absent on both days

xx) For the insurer Sh. Rajeev Sharma, Sr. Legal Manager



1)Smt. Muniya( Complainant) had filed a complaint against decision of PNB Met Life

Insurance Company ( respondent) alleging Repudiation of Death Claim under the policy no.

22540881

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0

2)The personal hearing in the case was fixed on 29.1.2020 and on6.2.2020. The



merits of the case.

3)Copies of the order to both the parties.


