Polinomios de Zernike y aberraciones

The life assured late Sri K.Bujjaiah, working as Work Inspector in Somasila Project, Bitragunta, took a Life Insurance Policy from Kavali Branch of Life Insurance Corporation of India under Nellore Division, as per the details furnished above. The policy was in a lapsed condition due to non-payment of premia due from 11/2000. The life assured got the policy revived on 25.06.2001 by submitting a declaration of good health form and paying the arrears of premia. The insured died on 05.03.2002 due to heart attack. Though the total duration of the claim was 1 year and 9 months, the duration from revival was just 8 months & 10 days. The claim under the policy was repudiated by LIC on the grounds of deliberate suppression of material facts, as the life assured

did not disclose his treatment for Epidydimo Arthritis, prior to revival of the insurance policy. It was also alleged that the life assured was on medical leave for 30 days during 11.09.2000 to 10.10.2000, which was also prior to revival of his lapsed policy. Smt. K. Padmamma, the nominee and complainant, represented to Zonal Office Claims Review Committee, Hyderabad for review. The ZO Claims Review Committee upheld the decision taken by LIC of India, Nellore Division. Aggrieved with the rejection of the claim, the complainant represented to this office.

DECISION:

I heard the contentions of both sides and also perused all the documents placed before me.

a) Section 45 of Insurance Act 1938 is applicable under the claim. The implication is that the LIC has to prove both materiality of the facts suppressed and fraudulent intent on the part of the life assured, before repudiating the claim; b) The life assured took a life insurance policy in 05/2000 for a Sum Assured of

Rs.50,000. The policy lapsed due to non-payment of premiums due from 11/2000. The life assured got the policy revived by paying the arrears of premia and also .submitted a Declaration of Good Health Form. Later, the life assured died on 05.03.2002. The duration of the claim from the date of revival was 8 months and 10 days. Since it was an early claim, the insurer arranged for investigation of the claim;

c) LIC repudiated the claim by setting aside the revival effected on 25.06.2001 on the ground that the life assured deliberately suppressed material facts relating to his health, prior to revival of the policy;

d) In support of the repudiation, the insurer obtained only a Medical Certificate dated 10.10.2000 issued by Dr.K. Subramanyam Raju of Nellore. This doctor diagnosed the disease as “Epididimo Arthritis” and was treated by him as OPD patient from 11.09.2000. This doctor also reported in the said certificate that the life assured was admitted as an in- door patient from 11.09.2000 and discharged on 10.10.2000. But the same doctor issued a certificate dt. 23.02.2003 marked as “whomsoever it may concern that K.Bujjaiah was

treated by him as a OP patient on 11.09.2000 - Diagnosis: Epidydino Arthritis. He neither underwent operation nor admitted-So, we are not maintaining any medical records-except my OP prescription”;

e) Though the employer of the life assured reported that the life assured availed leave on sick grounds, the employer did not furnish copy or copies of leave applications submitted by the life assured to them at the time of availing the leave;

f) When Sec.45 of the Insurance Act, 1938 was applicable under the claim, the insurer must have obtained complete and full particulars of the treatments like prescriptions, indicating the medicines used by the insured, the relevant case sheets, details of reports relating to pathological tests, etc. so as to sustain their repudiation action. In the instant case, the doctor who attended on the life assured categorically reported that the life assured was treated as an. OP only and that they were not maintaining any records;

g) Incidentally, the investigating official of LIC, who enquired into the bonafides of the claim reported that the life assured was maintaining good health and the death was sudden, due to heart attack;

h) Further, I also do not find any nexus between the facts suppressed to the cause of death of the life assured on 05.03.2002. If the suppressed facts had a real nexus with the death of the life assured, the insurer should have obtained and produced independent, cogent and believable opinions from Medical Experts, before the Insurance Ombudsman to drive home its contentions;

i) Having regard to the facts and circumstances, as discussed above and in the absence of any supportive/concrete evidence to the effect that the life assured had fraudulently suppressed material facts relating to his health prior to revival of the insurance policy, I am of the view that it is only fit and proper to direct the insurer to settle the claim under the above policy;

j) Therefore, for the reasons as aforesaid, I hold that the repudiation of the claim under the policy by the insurer is not legal, correct, proper and justified.

k) I, therefore, direct the insurer to settle the claim under the above policy for full sum assured.

The complaint is allowed.

Hyderabad Ombudsman Centre Case No. L-2048/2003-04

Smt. Ashw ini A. Karadi Vs.

Life Insurance Corporation of India Aw ard Dated 30.1.2004

Sri Ashok C.Karadi working in Navy as Lt.Cdr. (Indian Navy) took an insurance policy on his life, details of which are as under:-

Date of Proposal : 28.03.1993 Date of Acceptance/FPR : 28.03.1993

Policy No : 630451258

Sum Assured : RS. 1,00,000

Plan & Term : 108-25 Date of commencement

of risk : 28.03.1993

Date of Death : 01.10.2002 Date of Rejection : 21.11.2002

Cause of death : Accident-Aircraft Crash.

FACTS OF THE CASE

Sri Ashok C.Karadi, working as Lt.Cdr. in Indian Navy serving with INS Hamsa took a life insurance policy from City Branch-I of LIC under Belgaum Division. He died on 01.10.2002. The cause of death was reported to be accident (Aircraft Crash). As the policy does not cover accidental death, while the life assured was engaged in his official duty performing aircraft operations, the claim for accidental benefit was rejected by LIC of India, Belgaum. The claimant represented to Zonal Claims Review Committee, Hyderabad who have also upheld the decision of LIC D.O.Belgaum.

I heard the contentions of LIC as the complainant did not attend the hearing and also perused all the documents including the written submissions of the complainant, placed before me:

i) The life assured, took a life insurance policy for a Sum Assured of Rs.1,00,000 in 03/1993 and died in an aircraft accident on 01.10.2002. The policy covered the risk of accident benefit and the life assured paid the extra premium also to cover the risk of accident benefit. LIC already paid the claim for Basic Sum Assured under the policy;

ii) The life assured was employed in armed forces and died in action. As per the Certificate of Lt.Cdr, Squadron Commander (AOL), Dabolim, Goa-403 801, “the

life assured died during an aircraft accident at Dabolim Goa on 01.10.2002, whilst taking part in the Silver Jubilee Celebrations (25th anniversary of INAS 315). He w as not piloting the aircraft”;

iii) LIC also obtained clarification from employer of the life assured viz. Commander, Squadron Commander, Goa vide their letter dated 15.01.2004 that the aircraft was authorised to carry service personnel only as passengers and the life assured was on duty on the day and travelling in the capacity of tactical observer;

iv) The clause 10.2(v) of the policy reads as under: “The corporation shall not be liable to pay additional sum assured if the death of the life assured shall take place as a result of accident while the life assured is engaged in aviation or aeronautics in any capacity other than that of a fare-paying, part-paying or non- paying passenger in any aircraft which is authorised by the relevant regulations to carry such passengers and flying between established aerodromes, the life assured having at that time no duties on board the aircraft or required descent duties”

v) Since death occurred while the life assured was engaged in performing his duty, as per the above clause and as per the clarifications furnished by the employer of the life assured the complainant is not eligible for accident beneft. In view of the above provisions, the action of the insurer, in rejecting the claim for accident benefit is justified.

The Complaint is “Dismissed”

Hyderabad Ombudsman Centre Case No. L-1136/2003-04

Smt. M. Anuradha Vs.

Life Insurance Corporation of India Aw ard Dated 30.1.2004

Sri Maddina Rama Mohana Naidu, S/o Sri M. Krishnama Naidu, doing business and a resident of Nellore took a life insurance policy, as per details mentioned below: -

Policy No. : 840586556

Sum Assured : Rs.2,00,000

Plan & Term : 93-25

Date of commencement

Date of Acceptance of Risk : 31.05.1999

Date of Revival : 29.09.2001

Date of Death : 30.07.2002

Date of Repudiation : 02.02.2003

Cause of death : AIDS