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
An ordinary Postal worker, born in a village Krishnarayapuram in the erstwhile Trichy District and now under Karur district. Elevated to the highest echelon of the Union as the General Secretary of the All India Postal Employees Union, Group C Central Headquarters at New Delhi and the Leader Staff Side of the Departmental Council JCM. 
Super Sir
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