Page 54 - Life Insurance Today January-June 2020

was sold to him while taking loan from Bajaj Finance Ltd.. Mrs. Nisha Mandlik
It is alleged that at the time of proposal wrong informa-
tion was given about SA and terms & conditions of the V/S
policy and further added that he has also not received the Bajaj Allianz Life Insurance Co. Ltd.
policy bond so far. He made request for cancellation of
Complaint No. BHP-L- 006-1617-0542
policy but no satisfactory reply was given by the respon-
dent. As per SCN the company first time comes to know of
the grievance of the complainant upon the receipt of his Brief Facts:- The insured was hospitalized from
19.05.2015 to 27.06.2015. Thereafter, claim was preferred
mail dated 20-Oct-2016 i.e. after the lapse of nearly 31
to respondent company which was rejected on the ground
months from the date of commencement of the policy, so
his request was rejected being beyond free look period. that as per the policy clause disease diagnosed in the wait-
ing period of the policy are not payable. It is further stated
that the insured died on October 2015, so the complain-
FINDINGS & DECISION:- During hearing, the represen- ant represent the claim to the grievance cell of the respon-
tative of the respondent company could not submit any dent but her grievance was not redressed. As per SCN there
proof of delivery of the policy. Hence, it emerged that the is history of AV Fistula done in 2013 (said surgery is done
complainant did not receive the policy and therefore In- for Hemodialysis) as per policy clause, the disease diagnosed
surance Company is advised to provide a duplicate policy in waiting period of the policy are not payable.
to the complainant.
FINDINGS & DECISION:- From the records, it emerged
Mrs Meera Sharma that policy was taken in 2011-12 and the hospitalization of
the policy holder was done from time to time till 2015. The
V/S respondent company has already paid the sum equal to the

Life Insurance Corporation of India total sum assured of Rs.6 Lakh to the complainant hence
the payment beyond sum assured is not payable as per the
Complaint No. BHP-L-029-1617-0555 T&C of the policy.

Brief Facts:- The complainant stated that she has con- Mr. Rajendra Singh
sulted at Gwalior, Birla hospital due to breathing problem
and was advised to replace valve, which was replaced at V/S
Mendata hospital, Gurgaon where she was admitted dur- Life Insurance Corporation of India
ing 05.11.15 to 17.12.15. She had also taken treatment at
National hospital, Bhopal. Then medical expenses claim was Complaint No. BHP-L-029-1617-0551
lodged to the respondent, but her hospitalization claim was
Brief Facts:- The complainant fallen down from tree at
rejected by the respondent company stating pre-existing
illness irrespective of prior medical treatment or advice. As height on 13.06.2015 due to which he got fractured his
spinal cord and become permanent disabled. He made
per SCN the claim was rejected due to pre-existing disease
claim for disability benefit under policy but it was denied
as per discharge summary of Medanta Hospital.
by the respondent. As per the DMR of respondent the dis-
ability is due to accident but could not comment on tem-
FINDINGS & DECISION:- During the hearing, the com-
porary or permanent nature of disability as improvement
plainant stated that she has submitted the affidavit that
is uncertain. Hence, the disability benefit is not payable as
the duration of sickness was less than three years. The In-
per the terms and conditions of the policy.
surance company’srepresentative admitted that based on
such affidavit the case was sent to DODRC for reconsidera- FINDINGS & DECISION:- From the records, it is clear that
tion of claim on that ground. Accordingly an Award is passed complainant is suffering from 100% disability. Therefore, I
with the direction to the Insurance Company to settle the direct the Insurance Company to settle the claim of the
claim of the complainant as admissible. complainant as admissible. T

Nobody can predict the future; the idea is to have a firm grasp of the present.

54 January - June 2020 Life Insurance Today