Sandeep had availed Housing Loan from SBI through whom he had been enrolled as a member of a Group Insurance Scheme on 12.09.2016, specifically designed for Housing Loan Borrowers of SBI group by SBI Life Ins. Co. In the

Sandeep had availed Housing Loan from SBI through whom he had been enrolled as a member of a Group Insurance Scheme on 12.09.2016, specifically designed for Housing Loan Borrowers of SBI group by SBI Life Ins. Co. In the good health declaration signed by him he had mentioned that he was never hospitalized for any critical illness or a condition requiring medical treatment for a critical illness as on date. This being a group insurance, no medical examination was carried out at the time of granting insurance cover. It is to be noted that unlike in individual proposal, where specific answer Yes or No are sought, for the questions on health, are not asked in the application for Group Insurance. Proposal form contains a Good Health Declaration clause where Sandeep had declared that he was in sound health. But unfortunately, Sandeep died on 18.01.2017 within 4 months 11 days of enrolling himself as a member of the Group scheme. The insurer denied the claim and alleged that Sandeep has suppressed material facts of his suffering from chronic liver disease. To establish pre proposal illness the insurer has submitted two discharge summaries in respect of hospitalization of the deceased life assured. As per the discharge summary of GEM hospital Sandeep was admitted on 13.07.2016 and discharged on 14.07.2016. X- Ray and Scanning reports of Abdomen revealed shrunken liver with coarse Cho pattern splenomegaly, cirrhosis of liver with portal hypertension. The patient was diagnosed for colitis and treated. The above hospitalization is prior to the date of proposal i.e. 12.09.2016. Subsequent to the date of proposal Sandeep was admitted at KMC Hospital Coimbatore on 23.11.2016 and discharged on 2.12.2016. He was diagnosed for Alcoholic cirrhosis of liver with portal HT, c/o abdominal distension, swelling of both legs. One of the Critical illness is defined in the policy as irreversible kidney/or irreversible liver failure. On a perusal of various documents it has been clearly established that Sandeep had concealed preexisting illness of Alcoholic Cirrhosis of liver disease, portal hypertension. It was also established that Sandeep was an alcoholic and smoker. Hence the insurer has denied the claim with the established material facts of his suffering from chronic liver disease. Sandeep's wife dissatisfied with the denial of the claim, filed a complaint against the insurance company and asks for a remedial action. Ombudsman in resolving this dispute analyzed the case on the following lines: Since on the date of proposal Sandeep had felt that he was in good health and declared that he was in sound health cannot be faulted. Further there was no evidence to say that he was ill on the date he signed the application. As per the insurer, the critical illness not disclosed in the present case is chronic liver disease. The terminology used in while defining critical illness is Irreversible Liver Failure. One cannot come to conclusion that Sandeep was suffering from irreversible Liver failure since as per records he was suffering from cirrhosis of liver. Further Sandeep may not be aware that he was suffering from Irreversible Liver Failure. Hence, Sandeep cannot be faulted for not disclosing his liver problem. In the present case Sandeep died on 18.01.2017 and, the policy was affected from 12.09.2016. There is a likelihood of his liver having got severely affected during the period of 4 months, in which case he has failed to make a true declaration to that effect before the insurer. Considering all facts and in order to render justice to both the parties an ex gratia amount of ₹1,00,000 is awarded by the Ombudsman in full and final settlement of the claim. The complaint is partially allowed. Based on the case given above, deal with the following issues: What is the procedure for making a complaint? Who is an Ombudsman and what are the eligibility conditions to become an Ombudsman? What is the role of an Ombudsman in suggesting Recommendations and awards? Is the award announced by the Ombudsman justified in this case?