Diferencias entre el estado de resultado y el estado de flujo de efectivo

AFFECTIVE DISORDER AND ASPIR ATION PNEUMONI A. It was also reported by the

authorities that the U/S abdomen (very poor Ultrasound w indow show ed bulky

pancreas w ith mild left pleural effusion, mild ascites, mild hepatomegaly w ith mild fatty changes;

e) The above admission and treatment clearly establish the fact that the life assured was not enjoying good health at the time of revival of the policy;

f) According to the under writing norms of LIC, had the life assured disclosed the above material facts at the time of revival of the insurance policy, they would not have considered the life assured for revival immediately as the life assured was reported to be suffering from the above diseases/ailments, even prior to revival of the policy;

g) It is beneficial to mention here that the 2nd part of Sec. 45 of the Insurance Act, 1938 is applicable as the repudiation of the claim wa s made after t wo years from the date of commencement of risk under the policy. The said provision lays do wn three conditions for the applicability of the second part of sect ion 45. (I) Statement must be on a material matter or the insured must have suppressed facts which it was material to disclose (2) The suppression must be fraudulently made by the insured and (3) The insured must have known at the time of making the statement that it was false or the insured suppressed facts which it was material to disclose. In other words, the insurer must ensure that its repudiation fulfills all the above 3 ingredients necessary for repudiation of the claim;

h) On a perusal of the hospital records, it is established beyond doubt that the diagnosis for the above disease was well before revival of the Insurance policy. In the circumstances of this case, therefore, the fraudulent suppression of material facts by the life assured is very clear. Revival of an insurance policy is considered to be a fresh contract between the parties and in the present case, the facts suppressed were obviously m aterial to the fresh assessment of the risk. From the foregoing facts of the case, it became evident that the life assured was not in good health at the time revival of the insurance policy from the insurer and he had conveniently suppressed the material facts of his ill health intentionally to defraud the insurer. Therefore, the fraudulent intention is also very clear, in that, the life assured had not disclosed the disease in the declaration of good health form submitted by him for the purpose of revival of his lapsed policy, although he was very much aware of the same;

i) It is a settled law that the contract of insurance is based on good faith. The information as to the insured having suffered from all the above diseases as confirmed by the hospital at Bangalore before the revival of the policy was established beyond doubt on the basis of the medical evidences submitted by the insurer. It is for the insurer to give correct information about his health while executing the declaration of good health form for revival of the policy, which he did not disclose at that time. This ground of incorrect information and false statement regarding his health make the revival of the policy as null and void;

j) Therefore, I have to hold for the reason as aforesaid and also in the light of medical evidences available on record as referred to above, the repudiation of the claim by setting aside the revival, by the insurer on the ground that the insured had fraudulently suppressed material facts relating to his health at the time of revival of the insurance policy has to be upheld on law as well as on facts and does not warrant any interference at my hands.

The complaint is, therefore, dismissed.

Hyderabad Ombudsman Centre Case No. L / 21 / 003 / 0299 / 2004 - 05

Smt. Sujayakumari Vs.

TATA AIG Life Insurance Co. Ltd. Aw ard Dated 31.1.2005

Facts of the Case : One Shri S. Nagesh, working as tax consultant and a resident of

Banglore, took a Assure 15 Years Life line (With Return of Premium) insurance policy for a Sum Assured of Rs. 400000 from TATA AIG Life Insurance Company Limited at Bangalore in 07/2003. The life assured died on 17.01.2004. T he cause of death was reported to be heart attack. Smt. Sujayakumari, who is the nominee and complainant under the policy, lodged a claim with the TATA AIG Life Insurance Co.Ltd. But the TATA AIG Life Insurance Co.Ltd., repudiated her claim on 31.03.2004, citing the reason that the life assured, while proposing for insurance, gave false ans wers to certain question in the proposal form. It was also stated by the insurer that they held indisputable proof to show that even before he proposed for the above policy, he suffered from diabetes mellitus since 10 years and was under treatment for Coronary Artery Disease since July 2001. He, however, did not disclose these facts in the proposal. Finding the life assured to be guilty of deliberate suppression of material facts relating to his health at the time of taking the insurance policy, the insurer repudiated the claim.

Decision : I heard the contentions of both sides also perused all the documents including

the written submissions of both the parties :-

i) The life assured took one Assure 15 Years Lifeline (With Return of Premium) Insurance Policy from TATA AIG LIfe Insurance Company Limited for a Sum Assured of Rs. 400000 in 07/2003. The insured was a tax consultant and resident of Banglore. He died on 17.01.2004. The duration of the claim from risk date was just 6 months and hence the insurer arranged for investigation into the bonafides of the claim;

ii) The insurer repudiated the claim on the ground that the life assured had suppressed material facts relating to his health prior to taking the insurance policy. According to the insurer, the life assured Suffered from diabetes mellitus since 10 years and was under treatment for Coronary Artery Disease since July, 2001 and took treatment in a hospital, prior to taking the insurance policy;

iii) In support of their repudiation action, the insurer obtained treatment particulars from Mallya Hospital, Banglore. According to the treatment particulars obtained by the insurer in the form of discharge summary, the insured was first admitted in the hospital on 01.07.2001 vide In-patient No. 68533 with complaints of breathlessness and h/o orthopnoea. The life assured was also reported to be having h/o diabetes mellitus and was on treatment. He was discharged from the hospital on 04.07.2001. The final diagnosis arrived by the hospital authorities was Triple Vessel Disease, Mild LV

Dysfunction and Diabetes Mellitus. It was reported in the discharge summary that the

life assured had Echo, which had shown LV dysfunction w ith symptoms of

pulmonary congestion. The insured also had Coronary Angiogram indicating Ischaemic Heart Disease ann Type-II Diabetes Mellitus. This admission and the

treatment thereto w as prior to taking the insurance policy;

iv) According to the treatment particulars obtained by the insurer from Narayana

Hrudayalaya, Bangalore, the life assured was admitted in the hospital on 27.06.2002 with complaints of H/o orthopnoea since 2 days/pedal oedema/abdominal distension and discharged on 29.06.2002. The final diagnosis arrived by the authorities was C AD-

Triple Vessel Disease; Congesti ve Cardiac Failure; Type 2 Diabetes Mellitus; Essential Hypertension & Diabetic Retinopathy and Nephropathy. This admission

was also prior to taking the insurance policy;

v) According to the discharge summary of Narayana Hrudayalaya, Banglore, the life assured was admitted there on 10.10.2003, vide admission no. 17196 with complaints of CAD-Triple Vessel Disease with diabetic nephropathy and discharged on 15.10.2003. The final diagnosis arrived by the hospital authorities was Ischaemia Cardiomyopathy,

Severe LV dysfunction, Cognestive Cardiac Failure, Diabetic Nephropathy and Chronic Renal failure;

vi) Further, according to the Lakeside Medical Centre & Hospital, Banglore, the life assured was reported to have had CABG at MIOT Hospital, Chennai and was a diabetic mellitus 15 years besides heart attack one-year back. This h/o of heart attack goes back prior

to taking the insurance policy;

vii) All the above admissions and treatments, when arranged chronologically, clearly

established beyond doubt that the life assured was not enjoying good health at the time of taking the insurance policy. In fact, the complainant herself, during the course of investigation also reported the above facts to the representative of the Insurer. T hey were well within his knowledge and life assured, therefore, ought to have disclosed them to the insurer while executing the proposal for insurance to enable the insurer to assess the risk in right perspective. Instead, he suppressed the information by not furnishing correct information to the relevant questions in the proposal form and thereby induced the insurer for issue of the policy;

viii) Incidentally, there is nexus bet ween the material facts suppressed and the cause of

death of the assured on 17.01.2004;

ix) Sec. 45 of the Insurer Act 1938 was not applicable under the claim as the claim was repudiated within t wo years. It is very much pertinent to note that if t wo years have not elapsed from the date of acceptance of the insurance policy/commencement of the policy, the insurer is under no obligation to prove that the suppression of material facts having a bearing upon the acceptance of the proposal is fraudulent in nature and it is sufficient for the insurer to prove that there was misstatement or incorrect statement or inaccurate statement of facts in the proposal to rescind the contract of insurance. In the case on hand, the insurance policy had run for just 6 months only and the life assured paid just one instalment premium;

x) As the contract of insurance being a contract of utmost good faith (ubberima fide), there must be complete good faith on the part of the insured and the insured is under a solemn obligation to make full disclosure of material facts whic h may be relevant for the insurer to take into account while deciding whether the proposal for the insurance polic y should be accepted or not. While making a disclosure of relevant facts, the duty of the insured to state them truly and correctly cannot be diluted;

xi) Therefore, I have to hold for the reasons as aforesaid the repudiation of the claim by the insurer invoking the provisions of 1st part of Sec. 45 of the Insurance Act 1938 on the ground that the insured had deliberately suppressed material facts relating to his health is sustainable on law as well as on facts and the decision of the insurer was legal, correct and proper and does not warrant any interference at my hands.

In the aforesaid circumstances, the complaint fails and is dismissed as devoid of any merit.

Hyderabad Ombudsman Centre Case No. L / 21/ 002 / 0312 / 2004 - 05

Smt. O. Padmavathy Devi Vs.

SBI Life Insurance Co. Ltd. Aw ard Dated 31.1.2005

Facts of the Case : One Shri Oruganti Venugopal, S/o late Kames wara Rao, a resident of

Madanapalli in Chittoor District in Andhra Pradesh took a Sudarshan Policy-Plan A in 11/2003 for a Sum Assured of Rs. 100000 from SBI Life Insurance Company Limited, Mumbai. The mode of payment of premium was quarterly. Accordingly, the premium were

payable on 21st November, February, March and August of every year. As per the Schedule -Part III: terms and conditions -premium Payments” A grace period of 30 days will be allowed for payment of quarterly/half-yearly/ yearly premiums and 15 days grace period for monthly premium options. If the premium is not paid before the expiry of the days of grace, the policy will lapse. If death occurs during the grace period, the Basic sum Assured will be paid after deduction of premiums then due and all premium falling the policy year”. In the instant case, the premium due 21.05.2004 fell due for payment. After allowing the grace period of one month, the premium had to to paid before 19.06.2004 This was not paid Hence the policy lapsed Inview of the terms and conditions of the policy, the insurer repudiated / rejected the claim of the complainant as the policy was not in force as on the date of death of the life assured.

Decision: I heard the contentions of both sides and also perused all the documents, placed

before me.

a) The life assured took a Sudarshan Policy-Plan A in 11/2003 for a Sum Assured of Rs. 100000 from SBI Life Insurance Company Limited. The date of commencement of risk under the policy was 21.11.2003. The mode of payment of premium was quarterly and the instalment premium was Rs. 874.00;

b) As per the schedule of the policy the premiums under the policy were playable on the 21st November, February, May and August of every year. The life assured paid premium upto 21.02.2004 only. Premium due 21.05.2004 was not paid by the life assured;

c) Now it would be relevant to refer to the terms and conditions governing the policy. According to Schedule - Part-III Terms and conditions (3) Premium Payment “a grace period of 30 days will be allowed for payment of quarterly/half yearly/yearly premiums and 15 days grace period for monthly premium options. If the premium is not paid before expiry of the days of grace, the Policy will lapse. If death occurs during the grace period, the Basic Sum Assured will be paid after deduction of the premium then due and all premiums falling due during the Policy Year”;

d) Now in the instant case, the life assured had to pay the premium due on 21.05.2004.

This premium had to be paid by him before 21.06.2004 (before expiry of grace period). But this was not done by the life assured. Hence the policy lapsed. According to the complainant, they sent a demand draft for the premium due only on 21.07.2004 and the same was received by the insurer on 30.07.2004. But the life assured died on 25.07.2004 itself. That is, the demand for the premium was received by the insurer after the death of the life assured;

e) The construction of the Insurance Policy including its terms and conditions will form the basis of Contract of Insurance;

f) In view of the above facts and the policy conditions, the repudiation/rejection of the claim of the complainant by the insurer invoking the terms and conditions of the policy is correct and proper and does not call for any interference at my hands.

The complaint is, therefore, not allow ed. The insurer is, how ever, directed to refund the premium due 21.05.2004 recei ved by him on 30.07.2004 in the form of demand draft, w ith interest, as per IRDA regulation, if not already done.

Hyderabad Ombudsman Centre Case No. L / 21 / 003 / 0367 / 2004 - 05

Smt. Shrimathi Ananth Vs.

Aw ard Dated 12.2.2005

Facts of the Case : One Shri Bejadi Anathashayana, S/o Shri B. Ramakrishnaiah, working

as Accounts Manager and a resident of Bangalore took a Nirvana Plan in 03/2003 for a Sum Assured a Rs. 200000 from TAT AIG Life Insurance Company Limited Banglore. T he life assured died on 05.05.2004. The cause of death was reported to be heart attack. T he life assured, while submitting the proposal for insurance on 22.03.2003. gave false ans wers to certain questions relating to his health in the proposal form. It was also stated by the insurer that they held indisputable proof to show that even before he proposed for insurance, he had symptoms of drooping of right eyelid in March 2002 suspected Occular Myasthenia. The life assured, howev er, did not disclose these material facts at the time of taking the insurance policy. Finding the life assured to be guilty of deliberate suppression of material facts relating to his health at the time of taking the insurance policy, the insurer repudiated the claim.

Decision : I heard the contentions of both part ies and also perused all the documents

including the written submission of the complainant placed before me.

i) The life assure took a Nirvana Insurance Policy in 03/2003 for a Sum Assured of Rs. 200000 from T ATA AIG Life Insurance Company Limited, Bangalore. The life assured died on 05.05.2004. The cause was reported to be heart attack. The duration of the claim was Just 1 year and 1 months only. T he claim was repudiated by the insurer on 20.07.2004 on the ground that the life assured had deliberately suppressed material facts relating to his health before taking the insurance policy in question;

ii) According to the insurer, even before the life assured proposed the above policy, he had symptoms of drooping of right eyelid in March 2002 and was diagnosed of suspected Occular Myasthenia, which was not disclosed, in the insurance application signed on 22.03.2003;

iii) In support of their repudiation, the insurer obtained medical prescriptions said to have been issued by Nethra Dhama, Super Speciality Hospital, Bangalore for the consultations, the life assured had for drooping of right upper eyelid-Ocular myasthenia. According to the medical prescription issued by this hospital, the life assured consulted them on 15.03.2002. This consultation, certainly is prior to taking the insurance policy in question;

iv) The only one piece of avidence the insurer relied upon was the above prescription as referred (iii) above which incidentally does not contain the name of the life assured or his address. The total lack of information about the patient besides supportive evidences like case sheet, register or record of myasthenia and its course of treatment lend support to the complainant’s contention that the life assured did not consult the hospital/doctor in 03/2002 and it was only in 02/2004, the insured had the problem. This was only after taking the insurance policy;

v) Thus, the evidence relied upon by the insurer is too flimsy to suffice for repudiation of the claim of the complainant;

vi) The life assured was reported to be an accountant with a private company. If the deceased life assured suffered from Myasthenia for as long as the insurer would like me to believe, he could not have conceivably carried on the job of an accountant: and the insurer could have obtained evidence in this regard at the work place of the deceased life assured. T he insurer did not muster such evidence. The benefit of doubt should go to the complainant and her contention that deceased life assured was afflicted wit h