Page 27 - Life Insurance Today April 2018

tinue with the policy if it was revived by the Respondent. than 10 years from date of issuance of the policy did not
He replied that he did not want to continue with the policy convince the Forum to admit the complaint. The complaint
and just wanted the premium returned. was dismissed.

The respondent submitted that the policy was purchased In the matter of
after fully understanding the features, charges, benefits
and terms and conditions thereof after duly signing the Mr. Dinesh K. Shah
proposal form. The policy document containing the terms Vs.
of the policy was duly sent to him with a letter informing
him about the free look period limit within which the can- Oriental Insurance Co. Ltd
cellation of the policy was possible. The complainant did
Complaint Ref No.AHD-G-050-1617-1342
not raise any objection during the free look period, which
he had raised in the complaint before the Hon.ble Om- Policy No. 14110048201514355
budsman. The policy was issued under a contract of insur-
ance whereby the policyholder is under obligation to pay The Complainant was covered under Individual Mediclaim
premium regularly as mentioned in the contract. The com- Policy for sum insured of Rs.100000/-. issued by the re-
plainant had not fulfilled his responsibility and let the spondent. The complainant was hospitalized from
policy to lapse. The Policy condition No. 12 stated “The 24.03.2016 to 02.04.2016 in Panchshil Hospital at
policy shall terminate when the Account Value is insuffi- Sabarmati for treatment of Buccal Mucosa Squamous cell
cient to support the Cost of Insurance for a period of three carcinoma. The claim for Rs.142621/55 was repudiated by
months”. During the period of nonpayment of premium the Respondent. The complainant submitted that his claim
the Insurance Company was on risk till the time the accu- for the treatment for oral cancer was repudiated by the
mulated value became insufficient to cover the risk as per Respondent on the ground that the disease was caused
the terms of the policy. Ultimately, the insurer was com- due to his tobacco chewing habit. He submitted that the
pelled to foreclose the policy and it happened due to fail- treating doctor had given a certificate explaining that to-
ure of the insured to pay the premium on due date. There- bacco chewing is considered as risk factor for several ail-
fore the respondent’s stand to foreclose the policy was ments like hypertension, Heart attack and malignancy.The
correct and within the policy conditions. The representa- certificate also stated that it was not confirmed that the
tive, in reply to a question, as to why they had not inti- patient (Mr.D.K.Shah) developed malignancy because of
mated the complainant about the depletion of the fund ? tobacco chewing only.
She replied that the terms and “conditions and the Sched-
ule of the policy carried the details of the policy including The Respondent’s representative stated that the claim was
an obligation on the part of the insured to pay the pre- rejected as per exclusion clause 4.8 viz. ”Use, misuse or
mium regularly and keep the policy in force. She further abuse of drugs/alcohol or use of intoxicating substances or
added that the clause No.12 provided for termination of such abuse or addiction etc.” and excluded payment of claim
the policy in case the fund was not sufficient to cover the for treatment of any complication due to any addiction. The
life insurance of the policy holder. The complainant was treatment papers of the complainant mentioned that he had
insured for Rs.25 lakh till the date of termination of the tobacco chewing habit. The representative therefore con-
policy. Had the unforeseen eventuality taken place, the tended that the repudiation was correct. The Respondent
company would have paid the insured amount. had repudiated the claim on the basis of Clause No.4.8 ac-
cording to which claim for any treatment in respect of any
The Complainant, an educated person, had purchased the ailment arising out of, either directly or indirectly due the
policy on 26.09.2005. He had not produced any proof to consumption, use, misuse or abuse of tobacco, intoxicating
show that he was misguided with wrong information like drugs and alcohol or shall not be admissible.
payment of premium for 3 years only to keep the policy
in force for the full term of the policy. The Terms and Con- WHO, Cancer council and National Health Portal also sub-
ditions were at the disposal of the complainant to read and scribe the view that tobacco chewing is a major cause of
understand it. Raising an issue after a passage of more mouth cancer. The complainant was dismissed. T

A brand for a company is like a reputation for a person. You earn reputation by trying to do hard things well.

Life Insurance Today April 2018 27