Death Claim

A) Mrs. Madhuben D. Patel V/s. Life Insurance

Corporation of India
The Respondent had on the basis of certificate of hospital
treatment and Discharge summary from the hospital showing
past history of the Deceased Life Assured as HTN + D.M+COPD
since 4 years, repudiated the claim on the ground of incorrect
statement and withholdment of material information with
regard to health of DLA at the time of filling up the Proposal
Form.
The Complainant stated that DLA had no such pre-existed
disease but was hospitalizd because of diarrhea and vomiting
caused due to eating Barfi (sweet made from milk) and
buttermilk simultaneously which resulted in to food poisoning.
The focus was supported by notings in the discharge summary
and certificate of hospital treatment.
This forum observed that after 2 years of policy, section 45 of
Insurance Act 1938 was operating against the Respondent and
Respondent failed to prove fraud as in Part-II of the said
section. Moreover there was no nexus between cause of death
and alleged past history as DLA was admitted for treatment of
food poisoning which was ultimate cause of death.
In the result, complaint succeeds.

B) Smt. Laxmi Sahu Vs. Birla Sun Life Ins. Co. Ltd.
(2010)
FACT:-
The husband of the Complainant had taken one Gold Plus
policy bearing no-001593774 from the Birla Sun Life Insurance
Co. Ltd. for sum assured of Rs.5,00,000/- and unfortunately
the he (the life assured) died on 21.05.2008 due to respiratory
failure.
Being the nominee under the policy, the complainant lodged
the death claim which was repudiated by the insurer on the
ground of suppression of material facts regarding the health of
the deceased life assured.
At hearing, the Complainant was present while the insurer did
not attend. But, subsequently on the next date of hearing i.e.,
on 19.03.2010 filed the Self Contained Note. The insurer
submitted that just prior to one month of submission of
proposal form, the deceased life assured consulted doctors for
his illness and had undergone some pathological test which
facts were no mentioned in the Proposal form by answering
questions relating to this as NO.
AWARD:-
The Honble Ombudsman observed that so far as insurance
contract is concerned, it is based on utmost good faith and
both parties should have adhered to it honestly. If good faith
and honesty is not observed by one party the other party may
avoid the liability.
In this case, the deceased life assured did not disclose the
truth while filled up the proposal form under heading medical
information by writing NO to the said questions. But, he had
consulted doctor and had done pathological test just one month
prior to the proposal. The deceased life assured was a teacher
and it cannot be said that he could not understand the
questions.
Thus, the omission made amounts to suppression of material
facts, which is a valid ground for repudiation. So, the Honble
Ombudsman opined that the repudiation cannot be said to be
illegal or unjust or arbitrary due to the valid ground of
suppression of material facts as regards the health of the
deceased life assured and thus the complaint stands dismissed.

C) Smt. Sabita Patra Vs. Life Insurance Corporation of
India
FACT:-
The husband of the Complainant had taken a policy bearing no-
571543169 from the LIC who died on 03.06.2008. Being the
nominee under the policy, the Complainant lodged the death
claim which was repudiated by the insurer on the ground of
suppression of material facts as regards health of the insured.
According to the insurer, the cause of death of the life insured
due to Malaria Fever, Arthritis and Diabetes Mellitus which facts
were not intimated to it before commencement of the policy.
So, the pre-existing disease has got direct nexus with the
cause of death and the omission of early treatment amounts to
suppression of material facts which is a valid ground to
repudiate the death claim.
On the other hand, the complainant submitted that her
husband took leave on the medical ground to avoid the work
load and there was no suppression of material facts.
AWARD:-
The Honble Ombudsman observed that the policy has been
issued to the insured showing the date of commencement as
28.04.2007 though the proposal date was 30.03.2007.
While submitting the proposal there is a provision that if any
change occurs in the position relating to health, proposer is
required to inform the insurer immediately. But, in the case in
hand, this was not done.
Moreover, the treatment after submission of the proposal and
before acceptance, the steps should have been taken to
intimate about the treatment and also the premium was not
paid fully, the balance premium was deposited later on.
At that period, the step could have been taken to intimate the
facts on treatment which cannot be said to be accidental
omission rather rightly it has been said that it is
misrepresentation or suppression of material facts.
However, the Honble Ombudsman opined that considering the
status of the deceased policyholder and the sum assured and
the circumstances leading to acceptance of contract, in the
interest of justice this forum can invoke its jurisdiction to grant
ex-gratia amounting to Rs.20,000/- to the Complainant as a
special case.