A was issued a Life Insurance 'Jeevan Anand' Policy No. 12345678 with sum assured of ₹ 5,00,000. B his spouse was a nominee under the said Policy. The date of commencement of the Policy was 4.12.2012. Unfortunately, on 2

CS Professional · Insurance - Law & Practice · PYQS · June 2021
A was issued a Life Insurance 'Jeevan Anand' Policy No. 12345678 with sum assured of ₹ 5,00,000. B his spouse was a nominee under the said Policy. The date of commencement of the Policy was 4.12.2012. Unfortunately, on 26.9.2015, due to unknown reasons A committed suicide. B lodged a claim with the Divisional Manager of XYZ Insurance Co. Ltd., but the same was rejected, vide letter dated 24.6.2016, on the ground that the deceased concealed material facts at the time of buying the insurance policy. B filed an appeal before the Zonal Manager of XYZ Co. Ltd. against the order of the Divisional Manager of XYZ Co. Ltd. The Zonal Office upheld the repudiation decision of the Divisional Office and dismissed the Appeal, vide order dated 9.11.2016. B then filed an Appeal before the Claims Disputes Redressal Committee, XYZ Co. Ltd. of India, no decision was taken by the aforesaid Committee for quite a long time. B then filed a complaint before the National Consumer Redressal Commission, New Delhi. The Complaint was contested by XYZ Co. Ltd. stating that after the death of the deceased life assured (for brevity 'DLA'), a claim was lodged which was immediately examined and it was found that the DLA was suffering from Bipolar Disorder (a mental illness) and had taken treatment from different places and this material information had been deliberately suppressed by him while taking the Policy. In the proposal form made on 2.2.2012, while filling the questionnaire regarding his medical condition, he answered in the negative. However, the deceased remained hospitalised at Neuro Psychiatry and Drug Deaddiction Rehabilitation Centre during 2008 to 2009 and later in 2015. Hence, the claim of the Respondent (B) was repudiated, vide letter dated 24.6.2016, pleading that there was no deficiency in service or unfair trade practice on the part of the Insurer and prayed for dismissal of the Complaint. XYZ Co. Ltd. further stated that the Consumer Courts at District and State levels erred in interpreting section 45 of the Insurance Act, 1938. According to section 45 of the Act, which has been amended w.e.f. 26.12.2014, Policy is not to be questioned on ground of misstatement after three years. It was further stated that the State Commission and District Forum failed to appreciate the law laid down by this Commission in other cases. In one of the case, the Policy was questioned after two years and the Hon'ble Commission had observed that as the insured made untrue declaration, as such the orders of the Fora below were set aside and the Consumer Complaint was dismissed. The Insurance company submitted that the insured was under solemn obligation to make true and full disclosure of information which was within his knowledge, in the proposal form and withholding of such information or making misstatement was a fraudulent act and breach of principle of utmost good faith and the insurer was justified in repudiating the claim under the provisions of section 45 of the Insurance Act, 1938. It was further submitted that both the consumers forums at District as well as State Level erred in appreciating that life insurance agents do not act as an agent of XYZ Co. Ltd. The agents work on commission basis, and there was no relationship of employer-employee or master-agent between the XYZ Ltd. and the agents. It also submitted that in various cases Hon'ble Supreme Court has held, "It is settled law that terms of the policy shall govern the contract between the parties, they have to abide by the definition given therein and all those expressions appearing in the policy should be interpreted with reference to the terms of policy and not with reference to the definition given in other laws. It is a matter of contract and in terms of the contract the relation of the parties shall abide and it is presumed that when the parties have entered into a contract of insurance with their eyes wide open, they cannot rely on definition given in other enactment. XYZ Co. Ltd. also mentioned that in the said judgement, Hon'ble Supreme Court also observed that, "In interpreting documents relating to a contract of insurance, the duty of the court is to interpret the words in which the contract is expressed by the parties, because it is not for the court to make a new contract, however reasonable, if the parties have not made it themselves." The District Forum directed the Petitioner to pay ₹ 5,00,000 being death claim of the deceased to the Complainant and ₹ 25,000 as Compensation for deficiency in service, unfair trade practice and mental agony suffered by the Respondent along with ₹ 10,000 towards cost of litigation. The above order was to be complied within 30 days of its receipt by the Petitioner (Insurance Company). Thereafter, they shall be liable for an interest @ 12% p.a. from the date of institution of this Complaint, till it is paid, apart from cost of litigation. Being aggrieved by the order of the District Forum, the Petitioner filed an Appeal before the State Commission. The State Commission, vide order dated 28.11.2017, dismissed the Appeal and upheld the order passed by the District Forum. It stated that the A took the life insurance policy on 4.12.2012, whereas he died on 26.9.2015 i.e. after a period of more than two and a half years from the date of commencement of the policy. Being aggrieved by the order passed by the State Commission, the Petitioner Insurance company filed the Revision Petition before this Commission (National Commission). According to B, the deceased was asked to simply put his signature on the proposal form and rest of the columns and answers were filled by the insurance agent. The entire proposal form was filled in the handwriting of the insurance agent. The deceased cannot be made responsible for concealing information, filed by the insurance agents. The Respondent's contention was that the insured was simply asked to append his signature and all other answers were filled in by the agent, in his own handwriting. The deceased cannot be held responsible for concealing any facts. This aspect is well covered by judgment in LIC Vs. Bina Joshi where the entries filled by agents, the policy holders were not blamed for concealing information. It is very clear that as per Section 45 of the Act in force when the proposal was made and Policy taken, no Insurance Policy can be repudiated after two years on the grounds of concealment/suppression of facts. The amendment to Section 45 providing a period of three years came later in 2014. The present case is covered by this section before its amendment and the deceased died after more than two years nine months after taking the Policy. In view of the above, National Consumer Commission confirmed the orders of the State Commission and the District Forum and dismissed the Revision Petition filed by XYZ Co. Ltd. From the information given above, answer the following questions: Explain the procedure of claims in case of different types of life insurance policies.

Answer & Explanation:

The main purpose of taking an insurance policy is that it should come in use in times of crises. Selection of the right policy from a good life insurance company with a healthy claim settlement ratio is the main requirement for buying a life insurance. The main function of an insurance company is to ensure easy and timely settlement of a valid claim in return for the premium paid by the insurer/policy holder. The procedure of claims in case of life insurance policies can be described as under: I. The Death claim settlement process is as under: Step One: Intimation to the insurance company about the Claim The nominee should inform the insurance company as soon as possible to enable the insurance company to start with the claim process. The details required for intimation are policy number, name of the insured, date of death, cause of death, place of death, name of the nominee etc. The claim intimation form can be obtained from the nearest insurance company branch or even by downloading it from the insurance company website. Alternatively, many insurance companies also have online forms these days on their website for claim intimation. Step Two: Documents required The nominee will be asked to furnish the following documents: Death certificate; Age of the life insured (if not already given); Original Policy document; Any other document as per requirement of the particular insurer or case related. For early death claims i.e. the claim that has arisen within three years of the policy being in force the company will do extra investigation to ensure it is a genuine claim. They might do the following: Check with the hospital if the deceased was admitted to hospital. In case of an air crash confirmation from the airline authorities check if the policy holder was a passenger on the plane. In case of death from medical causes, the insurance company will ask the hospital to provide doctor's certificate, treatment records etc. If the policy holder dies due to murder, suicide, accident then police FIR report, panchanama, post mortem report etc. shall be required. Step Three: Submission of required Documents for Claim Processing For quicker claim processing, it is essential that the nominee submits complete documentation as early as possible and any other documents that the company needs to pass the claim. Step Four: Settlement of Claim As per the Regulation 8 of the Insurance Regulatory Development Authority of India (IRDAI) (Policy holder's Interest) Regulations, 2002, the insurer is obligated to settle a claim within 30 days of receipt of all necessary documents including extra documents sought by the insurer. If the claim requires further investigation, the insurer needs to complete its procedures within 6 months from receiving the written intimation of claim. II. Maturity & Survival Claims The payment made by the insurance company on completion of term of policy or maturity date is called maturity payment. The amount payable consists of sum assured plus any bonus/incentives. The insurance company informs the policy holder in advance by sending bank discharge form for filling details in it. The form needs to be returned back to the insurance company with original policy document, ID proof, Cancelled Cheque and copy of pass book. III. Rider Claims Different riders can be attached to the base life insurance policy for enhanced protection. The riders can be accidental rider, critical illness rider, waiver of premium rider etc. For different riders, different claim proceedings are required. Some riders may be valid with the death claim like accidental death rider or some riders need to processed standalone like waiver of premium rider in case of disability. IV. For Critical Illness Rider Necessary medical documents such as first diagnosis report, Doctor's report, etc. are required. For Accidental disability rider copy of FIR, Certificate of disability by the treating doctor, doctor's report etc. are required. In many cases, life insurance claims have been delayed or denied due to lack of proper documentation or simply because the proper claim process was not followed. Hence, it is recommended that the claimant should be aware of the claim process in order to have a hassle-free claim settlement process during the emotionally draining time especially while filing a death claim.

Topics: Life Insurance Claims

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