After five years of fighting, the husband wins his health insurance claim against LIC for Rs 1.57 crore

After five years of fighting, the husband wins his health insurance claim against LIC for Rs 1.57 crore

LIC Health Insurance Claim: The NCDRC ordered Life Insurance Corporation of India (LIC) to reimburse the spouse of a policyholder who passed away from breast cancer in 2017 of Rs 1.57 crore. In 2016, LIC adopted the aforementioned policy after Eco and Medical. The policyholder carried out the examinations.

The spouse of the dead policyholder received an order from the National Consumer Disputes Redressal Commission (NCDRC) directing Life Insurance Corporation of India (LIC) to pay him Rs 1.57 crore. April 2017 saw her death from breast cancer, and in March 2018, LIC denied her husband's insurance claim. According to NCDRC's ruling, LIC gave subpar service in 2018 when it denied the insurance claim when it ought to have fulfilled it.

The insurance was a health premium coverage where the insured got a payout of Rs. 7,00,000 and a payment of Rs. 1 crore upon payment of an odd amount as premium. The standard medical and environmental examinations were carried out prior to approving the aforementioned policy, and on March 29, 2016, it was accepted. The date of the premium payment and receipt issuance was March 30, 2016," LIC said in front of the NCDRC.

chronology of the events

Below is a list of all the deadlines that applied to this case.

The lady who has passed away sent the proposal form to LIC on February 6, 2016.

LIC orders Echo and other medical tests on March 3, 2016.

LIC authorized the insurance on March 29, 2016. This day also happened to be the policyholder's hospital admission.

March 30, 2016: LIC provided a receipt upon payment of the Rs 7 lakh premium. Her hospital of admission ordered a biopsy in addition to other procedures.

March 31, 2016: The hospital performed a biopsy and other required medical testing.

On April 6, 2016, the hospital released him.

Policy extended for another year on March 30, 2017.

On April 28, 2017, breast cancer claimed her life.

March 8, 2018: On this day, LIC sent a letter stating that it has decided to deny the insurance claim.

Why was the health insurance claim rejected by LIC?

LIC's principal rationale for rejecting the claim was that the policyholder had not disclosed to the insurer that she had breast cancer at the time of policy acquisition or renewal.

The insured was receiving treatment at the NRI Hospital for probable cancer, and this information was withheld from the declaration that was needed to be provided while the resolution was pending, according to LIC. As there was no knowledge on health issues, the policy was finalized on March 30, 2016, with the best of intentions. Had the policy been in place on or before March 29, 2016, and the proposed life's poor health had been brought to our attention right away, we would have submitted the case to our corporate office and made the proper choice in consideration of the completion payment."

In 2018, the spouse of the deceased expressed disappointment at the insurer's denial and filed an appeal with the NCDRC.

In NCDRC, fighting breaks out

He had medical exams on March 30 and 31, 2016, and was then released from the hospital by recommendation from his physician. The complainant claims that he subsequently learned that his spouse had breast cancer.

"The claim was made in the background mentioned above following his passing on April 28, 2017." It is noteworthy that on March 30, 2017, the insurance was renewed with another premium payment of Rs 7,00,000/-. And peculiar. The insurance company has not been able to prove, based on the case's circumstances, that the insured withheld any information that would have violated the declaration provision. Therefore, on or before March 30, 2016, neither the complainant nor the insured was aware of the unfavorable event, according to the NCDRC.

Lawyers for LIC refuted the NCDRC's claim, arguing that the insurance proposal form itself is where these statements of medical problems originate. "If such medical information is in the knowledge of the insured after the day of signing of proposal submission and fails to be disclosed then it will invite exclusion as well as rejection under the insurance policy," stated LIC.

The complaint said that despite his wife's admission to the hospital on March 29, 2016, for discomfort in her left side, the hospital had not disclosed any unfavorable conditions at the time of her release. Moreover, specifically, he was not made aware of any unfavorable events prior to March 30, 2016, the date on which the premium insurance was submitted and received.

"In actuality, there is no proof that any unfavorable health condition existed that needed to be disclosed on the proposal form. The NCDRC said that "the insurer's above argument lacks substance and should be rejected in the absence of such evidence."

NCDRC directive

Following a thorough evaluation of all available data and reasoning, the NCDRC issued a ruling supporting the policyholder. It says as follows: "The complainants' claims are obviously false, and the opposing party, Insurance Co.The business, which is responsible for paying the complaint under the provisions of the insurance, has a blatantly inadequate level of service."

The following honors were granted:

Amount Guaranteed: Rs 1 crore plus 9% interest from the date of obligation under the aforementioned insurance policy; moreover, Rs 2 lakh plus 9% interest for psychological distress and intimidation; and Rs 50,000 for legal fees.

Overall, he will get Rs 1 crore plus interest (1 crore x 9% x 6 years). Additionally, the complainant would get Rs 2 lakh plus Rs 1.08 lakh in interest (2 lakh x 9% x 6 years). To bring the total compensation to Rs 1.5758 crore (Rs 1,57,58,000), the claimant will additionally get Rs 50,000 as litigation costs.