One interesting case that the RPLI claim was rejected by the department as if the insurant has suppressed information about his illness at the time of taking the policy. Our team Com Gurusivam had helped the family by drafting the following and accordingly the claimant was paid the insured amount. This is the forum I am keeping open and any comrade who is willing to share his draft for publishing it is welcome. But the decision is mine.
Kayveeyes
Sub: Submission of Appeal against rejection of death claim of RPLI policy no: ………..
Ref: Postmaster, ………… HO letter no.PLI/RPLI/Death claim dlgs dated ……….
Having profound regards, full faith in your sense of justice, fair play and allegiance in law and justice, I earnestly submit the following appeal against rejection of death claim preferred by me (nominee) in respect of RPLI policy no. ………. for your benign consideration and orders. The letter cited under reference is received by me on ………….
1-2 : It was extremely shocking and appalling on the receipt of letter from Postmaster………… HO dated ………, where in it is communicated that the death claim=preferred by me (nominee) in respect of RPLI policy no. ………… is rejected stating there is a ground for suspicion on suppression of facts and statement of health given at the time of policy to be false.
1-3 : With fervent hope in anticipation of positive response, I beg to submit this appeal as envisaged in PLI Directorate letter no.25-04/SOP/2020-LI dated 17.12.2020.
PRELUDE:-
2-1 : This is just an introduction which I believe would be of immense help especially to Appellate Authority Postmaster General …….. in understanding the very facts on which death claim is rejected and also the awful dispensations of almost a good number of officers, who had a significant role in rejection of death claim, amply manifest pervasively throughout, exposing the lack of rudimentary knowledge in PLI/RPLI death claim rulings like the one being discussed in the following paras.
2-2: On ………., I along with my Husband visited ………. Post office only to deposit into POSB schemes. We have no idea of taking RPLI policy. Postmaster,……… SO canvassed and insisted to take RPLI policy. It is pertinent to mention here that only because of her, we inclined to take RPLI proposal. Hence on ………. RPLI policy ……….. of Sum Assured Rs.10 lakh with Annual premium of Rs.74007 has been taken by my husband and I have also taken RPLI policy (………….) on the same day for Rs.33950 premium +GST.
2-3: My husband policy (Policy no: ………….) has been accepted on …………… by Regional DPS, ……... On ………, my husband Shri.Late ……… told me that his heart aches and at once I rushed with him to ……….. hospital, …….. for treatment around 08.30 PM but my husband expired at hospital on …….. at about 09.22 AM. He was healthy and never reported as such before.
ENDORSEMENT OF FACTS SUBMITTED BY THE PROPOSER AND ACCEPTANCE OF POLICY BY APPROVING AUTHORITY:-
3-1: Details provided in the RPLI proposal form has not been disputed but verified & endorsed by the approving authority eventually policy has been accepted on ………..
3-2: In the check list cum confidential report given by RPLI agent to point no.9 (Annexed as Enclosure-1) , RPLI agent Smt……….. has mentioned as “Yes” to the question “ Have you inquired about general health condition of the proposers and confirm that he/she is not suffering from any serious/terminal illness. Sales person also submitted that in declaration form from marketing staff for High value policies (Annexed as Enclosure-2) RPLI that proponent is in good health & financially sound and proponent would continue to pay the premium regularly.
3-3: In proposal form point no.11, i.e in Declaration by Agent, Sales person declared that she fully aware about the financial/physical/mental situation concerning proposer and further undertook that she had carried out required verification & completed the confidential report. Hence it is evident that sales person has verified all details relating to health condition and financial position and satisfied herself. Hence she recommended the acceptance of policy.
3-4: It is worth mentioning here that vide RPLI proposal form (Annexed as Enclsoure-3) point no.11, Department of Posts appointed medical examiner for examining PLI/RPLI proponents have declared that proponent is medically fit and he does not suffer from any terminal illness or serious health hazard which would be risk to his life, further recommended acceptance of the policy.
3-5: It will not be out of place to mention that Divisional head in his confidential report (Annexed as Enclsoure-4) has recommended the acceptance of policy
3-6: A kind attention is invited to the ……… Region office note on the subject acceptance of RPLI proposal ………. (Annexed as Enclsoure-5) wherein, OA, ASP(RPLI), ADM(RPLI) & Regional DPS has signed in token of verifying the details furnished in the proposal & relevant supported documents . Regional DPS, ………… Region accepted the policy.
3-7: Insurer in his declaration stated that he is not suffering from hypertension & Diabetes Mellitus ( Annexed as Enclosure-6)
CAUSE OF DEATH:-
4-1: It has been stated in death summary (Annexed as Enclosure-7) that proposer is known case of CAD for past 1 month (i.e from 17 March 2020) but policy accepted on 3rd ………... It is also stated that proposer is a known case of Type 2 DM for 6 months.
4-2: In the opinion of the death of proponent dated nil by …….. Hospital(Annexed as Enclosure - 8) has stated that CAD is the main factor responsible for the death and known case of CAD since 17.03.2020 and the proponent might have aware of the disease as of ………
4-3: Inspector Posts, ……. Sub Division in his report dated 16.04.2022 ( Annexed as Enclosure- 9) endorsed doctor opinion of death of proponent i.e
“xxxx the last attended doctor is not sure about the awareness of disease by the insurant/claimant prior to taking this policy but had stated that there is lesser probability to have known about the same”
4-4: From the above, it is clearly construed that CAD is the factor that led to the death of the proponent and not Type 2 DM.
DEFECTIVE BASE - A CASE OF NO EVIDENCE:-
5-1: If proper mind is applied and looked into this case, it is that the report of field officer i.e IP, …….. Sub Division that forms the basis for rejection of death claim and every officers who are about to dealt with this death claim relied upon field officer report only albeit there is no material evidence to be relied upon.
5-2 : Inspector Posts, ………. Sub Division in his inquiry report dated ………. stated that proponent is welding labourer but had taken policy for SA 10 lakh with half yearly premium of Rs.70820. Inspector Posts, ……… Sub Division in his report dtd ………. also reiterated the same i.e. the policy taken with half yearly premium of around Rs.70000/- . This clearly shows IP, …….. sub Division drafted inquiry report bearing Rs.70820 as half yearly premium in his mind and this is just an example how depth he looked & inquired in to case by applying his mind.
5-3: IP, ………. Sub Division in his report dated 16.04.2022 stated proponent as
“Welding labourer” but contradictory in his report dated 05.08.2022 stated as selfemployed. Reality is, he is not just welding labourer but proprietor of M/s ………….. Design Welding labour works ( Letter pad & Visiting card annexed as Enclosure-10) located at …………..Thus it is evident, field officer did not make inquiry in proper manner.
5-4: It is worthwhile to mention here that proponent deposited around Rs.9.5 lakh in POSB schemes at …….. Post office on 26.12.19 & 09.01.2020.
5-5: It is pertinent to mention that Proponent was enrolled in Tamilnadu Chief Minister Insurance plan (photocopy of Insurance card annexed as Encl-11). If there is any medical complication, proponent would have availed treatment under Tamilnadu Chief Minister Insurance plan as it is free of cost. But proponent did not claim any using Tamilnadu Chief Minister Insurance plan.
5-6: Inspector Posts, ……… Sub Division inquiry report dated 16.04.2022 stated that statement dated 01.12.2021 recorded from Shri……….. and in that statement both deposed that the proponent led a healthy life only. This is also not taken into account.
5-7 Hence the version of Field officer report dated 16.04.2022 & 05.08.2022 “ that insurant is only a welding labourer but taken policy for SA 10 lakh with half yearly premium payment of around Rs.70000/- and that too at a time when he was already suffered with medical complications and he would have in need of money for treatment also at that time” is totally baseless and it is merely on conjectures, surmises, guesswork and whims without considering the material fact that proponent is financially healthy to pay the annual premium and did not have medical complication at the time of taking the policy. It is crystal clear that IP, ……….. Sub Division has preconceived decision of not recommending the case.
ALLEGED SUPPRESSION OF FACT:
6-1: Proponent in his declaration stated that he is not suffering from hypertension & Diabetes Mellitus (Annexed as Enclosure-6). In death summary, it is stated that it is a known case of Type DM-2 for 6 months.
6-2: Being his wife, upto my knowledge he did not suffer from either hypertension or diabetes. He never took treatment for diabetes. Only on 17.03.2020, it came to know sugar level is up to slight extent than normal.
6-3: It is evident from the death summary & doctors opinion letter that CAD is the main factor which attributed to demise of proponent. As such, rejecting death claim stating that suppressed the fact of having Diabetes Mellitus is not in conformity with rulings.
6-4: It is submitted that Type 2-DM has no correlation with the actual cause of death of the insured, which was due to CAD. Ergo, the suppression as alleged in any event cannot warrant repudiation of the policy. In support of such contention, reliance is placed on the decision of supreme court in Sulbha Prakash Motegaonkar Vs LIC,India (CIVIL APPEAL NO. 8245 OF 2015, Arising out of S.L.P. (C) No. 13589 of 2015)
6-5: It is necessary to consider as to whether non-disclosure of ailments had a correlation with the cause of death and ailment of Type 2 DM that the proponent was alleged to be suffering from was not a life threatening disease which could or did cause the death of the insured
6-6: Last but not least, if the proponent intention is to attain benefit by availing RPLI, perhaps he would have taken the RPLI policy for sum assured 10 lakh by paying the monthly premium. He would not have opted for yearly premium.
6-7: In the Doctor report, it is furnished that proponent might have aware of the disease by 16.12.2019. This is the opinion of the doctor and not the fact. No material evidence for the opinion of the doctor. The word “might” could not be equated with should. It denotes that possibility but not certain. Strong suspicion, strong coincidences and grave doubt cannot take the place of legal proof. The suppression of facts must be cogently and firmly established and in this case it is not so.
LACUNAS IN DEALING DEATH CLAIM:-
7-1: Sales agent declaration that she fully aware about the financial/physical/mental situation concerning proposer and recommended the acceptance of policy has not taken into consideration
7-2 Due importance is also not given to declaration of the department appointed medical examiner for examining PLI/RPLI proponents who has declared that proponent is medically fit and he does not suffer from any terminal illness or serious health hazard which would be risk to his life and recommended acceptance of the policy. There is no mention anything about medical examiner declaration in the inquiry report=
7-3: Confidential report written by Divisional head was also not taken into concern. Relying only on the vague report of IP, ……….. Sub Division will not be in consonance with the fact and report of IP, ……….. sub division is liable to vitiated.
7-4: In the letter rejecting the death claim, it is stated that there is a ground for suspicion in suppression of facts. It is crystal clear that decision is made on surmises & suspicion and not based on material evidence.
PRAYER:-
From the above, it is evident that alleged concealment of Type 2 DM was not of such a nature as would disentitle the deceased from getting his life insured and also not the cause of death of insurant. Taking cognizance from the above, I humbly beseech the Erudite Postmaster General ………Region, to kindly cause to issue order for settling entitled death claim amount to me, which will be immediate succour to the bereaved family.
Once again thanking you in anticipation.
Sanguine of Justice
Courtesy : https://yourskayveeyes.blogspot.com/
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