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Insurer faulted for failure to detect disease

The state consumer commission has directed LIC to pay around Rs 44,000 in compensation plus the insured amount to a widow whose claim it rejected on the grounds that her husband had suppressed the fact that he was suffering from HIV while applying for the insurance. The commission said the medical check-up done when the man applied for insurance should have detected he had HIV as well as tuberculosis.

LIC has to pay the woman a total of Rs 1.34 lakh.

Reprimanding the insurance company, the Maharashtra State Consumer Disputes Redressal Commission said that it was extremely difficult to believe that the mandatory medical examination and the doctor's examination of the insured person failed to assess and detect a prolonged ailment and symptoms of tuberculosis and HIV. The commission said that the insured person also may not have been aware of the infections and changes taking place in his body. "He, therefore, cannot be attributed to have suppressed material information consciously and intentionally while filling the proposal form of the insurance company."

The husband of the complainant had taken Jivan Mitra (Triple Cover Endowment) from the insurance company and it was effective from March 10, 2004. On July 25, 2005, the man died of acute chronic renal failure. His widow then filed the claim. On May 20, 2006 the insurance company rejected the claim while alleging that while filling the proposal form the deceased had hidden the fact that he was suffering from HIV and TB. The company said the diseases were recorded in the history submitted by the deceased when he was getting admitted to hospital.

Aggrieved, the woman filed a complaint in a district forum. On July 18, 2007, the forum dismissed the complaint, following which she filed an appeal in the state commission. The woman submitted that the deceased was unaware of the ailments cited and died of a totally different reason. She said there was no correlation between the illness history and cause of death.

The insurance company alleged that the discharge papers of the Pune hospital showed that the deceased was suffering from HIV and TB for two years prior to giving the history.

The commission observed that the discharge card was not tendered in evidence. "There is no evidence as to who had received the said history and as to who had given it. Under the circumstances, its authenticity as well as correctness can be doubted. Hence, the very basis of the insurance company's repudiation gets blown off," the commission said.

Refuting the insurance company's defence, the commission said, "We find that the insurance company failed to show that the deceased suppressed material information while filling a proposal form. Thus, the repudiation of insurance claim being arbitrary, the deficiency in service on part of the insurance company is well established."

Article referred: http://timesofindia.indiatimes.com/city/mumbai/Insurer-faulted-for-failure-to-detect-disease/articleshow/19589364.cms

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