PER:

Charanjit Singh, President

1        The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 12 against the opposite parties on the allegations that the complainant is bonafide resident of above mentioned address. Late husband of the complainant namely Jit Singh had got his life insured from opposite parties by life insurance policy. The opposite parties had issued an insurance policy No.  5001-8130855 and date of commencement of policy was 28.10.2018. The deceased insured Jit Singh had named the complainant i.e. his wife in his life insurance policy as nominee. The complainant becomes the consumer of the opposite parties. The insurance taken was under the plan of Bharti AXA Life Super Endowment Plan with guaranteed sum assured of Rs. 6,00,000/- and was having survival benefits to the nominee to the tune of Rs. 3,00,000/-. During the continuation of life insurance policy, the insured met his unfortunate death on 4.1.2019. The death was timely intimated to the opposite parties and its concerned officials and death claim was made with the opposite parties by the complainant. The information regarding the death of the insured was given to the opposite parties through its representatives, who visited the house of the complainant. The complainant presented all the necessary documents to substantiate the death of Insured. The representative who visited the house of the complainant took all the documents such as original policy documents, documents pertaining to policy, claim, death proof etc. with an assurance that the claim will be settled at the earliest and the documents will be returned. The complainant is rustic person and is not aware of the technicalities of insurances and is neither well educated nor well conversant with the English Language, the officials of the insurance company use to take all the documents, letters received from the complainant on the pretext that they are helping the complainant and soon her claim will be settled. Thus believing upon the assurances of the officials of the insurance company the complainant very innocently handed over all the documents received or asked by the officials of the insurance company. Till date the complainant has requested the officials of the opposite parties and pleaded with folded hands many a times to kindly settle the claim made on the death of her husband but all in vain, the complainant is made to wait for no reason and her repeated requests were ignored causing mental trauma, mental harassment to her. The complainant was made to wait for one reason or another but neither the claim was settled nor any response was received by the complainant on her requests and hence the complainant was forced to file the present complaint. The opposite parties sent investigator and while investigating the claim, official representing himself to be investigator of the company of the opposite parties, came to the complainant and demanded huge amount for passing the claim of the complainant. The complainant did not oblige the investigator, so the investigator has submitted the report against the complainant. The opposite parties are intentionally harassing the helpless and rustic people by over delaying and withholding the genuine claim on flimsy and untenable grounds. The deceased Jit Singh met his unfortunate and untimely death during the continuance of the insurance policy, so the complainant is entitled to complete assured sum as per the policy alongwith all its benefits and prayed that the opposite parties may be directed to decide the claim and to release the sum assured i.e. amount of Rs. 6,00,000/- as sum assured and Rs. 3,00,000/- as survival benefits which the complainant is entitled as per policy due to the unfortunate death of insured Jit Singh during the continuation of policy alongwith interest to the tune of 18% P.A. till its full and final realsiation alongwith  Rs. 1,00,000/- as compensation for mental torture and agony and Rs.  25,000/- as litigation expenses. Alongwith the complaint, the complainant has placed on record her affidavit Ex. C-1, policy document i.e. welcome letter receipt of first premium policy schedule Ex. C-2 to C-4, copy of death certificate, copy of claimant statement form as filed by the representatives of the opposite parties Ex. C5, C-6.

2        Notice of this complaint was sent to the opposite parties and opposite parties appeared through counsel and filed written version by interalia pleadings that the complaint filed by the complainant is not maintainable and is liable to be dismissed as the complainant has attempted to misguide and mislead this commission. In fact, the complainant has suppressed material facts from this Commission and as such the complaint is liable to be dismissed. The opposite party does not have any branch office at Tarn Taran. Further the Proposer Form has been executed in Jalandhar and thus present complaint lacks territorial jurisdiction in the matter and deserves to be dismissed, as per Sec 11 of C.PA. 1986 complaint can be instituted at a place where the complainant has raised the policy under question i.e. Policy bearing number 501- 8130855 and same is an outcome of a fraud which has been played on opposite party Company. The present policy was an outcome of a fraud as the identity of the Life Assured is disputed and the mere existence of the Assured can also not be ascertained. Even the alleged date of death of the Life assured is disputed. The investigation which was necessitated because of various frauds being committed on the insurance companies and examined the matter in detail and possessed evidences which establish that there is dispute with respect to the identity of the assured and his mere existence. The opposite party was misled to issue the aforesaid policy on the life of the alleged Mr. Jit Singh. Furthermore, the policy was acquired through forged documents and by a well planned criminal conspiracy involving various individuals including the present applicant. This commission has no jurisdiction to entertain the present application. In the present case, there are serious issues of forgery, fabrication, cheating and misdeeds. Such serious allegations require a proper trial by a civil/ criminal court and evidence has to be taken which is not possible in a summary trial.  In the instant case there has been a deliberate attempt to defraud the Respondent Company of a huge sum for which the opposite party Company is contemplating to launch appropriate criminal proceedings against the applicant and other involved in the fraud in order to wrongfully obtain the subject policy from the opposite party Company. The contract of insurance is a void contact. Furthermore Life insurance claim payouts are made from the pool of funds of many consumers of the services of an insurance company. Hence, to honour an illegitimate claim, would mean doing injustice to other genuine Policyholders. Hence, even entertaining the said case would be against the principles of natural justice and this would not be in the interest of consumers of services of a life insurance company. The malafide intentions of the complainant and the fraudsters is also clear from the fact, no medical documents have been submitted by the complainant till date. The idea of the fraudsters to directly file this present complaint was to avoid any thorough investigation into to the matter, whenever any claim is submitted a thorough investigation has to be done regarding the same, the identity of the claimant has to be verified, the genuineness of the claim has to be verified, the status of the policy has to be checked and if it is in accordance with the policy terms & conditions then only the claim can be processed. The complainant has with malafide and dishonest intention has twisted and distorted the same to suit her own convenience and to mislead this commission as such the present complaint is not maintainable before this Commission. The present case is a perfect example of a very well- planned Organized Fraud against the opposite party Company and the entire insurance industry Insurance fraud is one of the most serious problems threatening viability of insurance companies Insurance frauds are driving up the overall costs of insurers and premiums for policyholders. It encompasses a wide range of illicit practices and illegal acts. The organized insurance fraud can be categorized into-

(a)     Internal Fraud: Internal frauds are those perpetrated against a company or its policyholders by agents, managers, executives, or other employees

(b)     External Fraud: External frauds are directed against the company by individual or entities as diverse as medical providers, policy holders, beneficiaries, vendors and career criminals

The Respondent would like to bring to the attention of the court that the present case is a classic case of an external fraud on the company on the basis of the location. That the Company has received various claims from location Tarn Taran and neighboring areas, wherein:

a)       The LA mysteriously dies within 3 months from the issuance of the policy.

b)      It is noticed that the Claimants do not provide any medical certificate from treating doctor or a medico legal cause of death.

c)       The identities of the assured are disputed. The mere existence of the assureds are also disputed

d)      Even the dead bodies get cremated in the absence of any doctor certifying the death or even when no post mortem is done to ascertain the cause of death.

e)       Pan Card and Bank Account and other documents are created before issuing of the policy:

In the present case too, the claim was received from Tarn Taran and the above mentioned nexus is clearly and blatantly evident. The company got investigation done and they revealed the following facts

1        During investigation the investigator first visited the address i e Akbar Mohalla, Kapurthala Road, Tarn Taran provided by the alleged insured but could not find his residence. The investigator met all nearby area people but no one knows about the insured, his death and his family

2        On the next day the investigator again visited the area and met different people. But again no one knew about the Insured, his death and his family

3        The investigator then called on the number provided and she called the investigator to Ferozepur where there were people present and were ready with the answers. This created considerable doubt as the people were clearly tutored

4        The investigator asked the nominee about her address at Tarn Taran but she could not confirm the same

5        The investigator searched the record of insured in main hospitals of Tarn Taran but no record was found by the name of the insured.

6        The investigator the again investigated in the nearby area of Akbar Mohalla and the bus stand and railway station along with photos of Insured and nominee but no one knew about them.

7        The investigator even visited the nearby cremation ground but no record of the insured was found there also.

8        Various other discrepancies were found.

All the above points clearly speak of the ill-intent and motive behind taking the insurance policy. The Complaint is devoid of any material particulars and has been filed merely to harass and gain undue advantage and unjustified monies from the opposite party. The application has been filed with ulterior motive and malafide intention to cause harassment and prejudice to the opposite party. This commission has no jurisdiction to entertain the present application. The applicant has failed to demonstrate any deficiency in service on the part of the opposite party. In the present case, the opposite parties have strictly acted as per the terms and conditions of the policy contract. The terms of the policy are in the nature of a contract and their interpretation has to be made in accordance with the strict construction of the contract. The opposite parties have denied the other contents of the complaint and prayed for dismissal of the same. Alongwith the written version, the opposite parties have placed on record copy of proposal form Ex. OPs/1, copy of claim statement Ex. OPs/2, Copy of investigation report supported by affidavit Ex. OPs/3Copy of repudiation letter Ex. OPs/4.

3        We have heard the Ld. counsel for the complainant and opposite parties and have carefully gone through the record placed on the file.

4        In the present case, according to complainant, Jit Singh has availed insurance from the opposite party and Jit Singh has since died and after his death, the complainant is entitled to his insurance claim. But on the other hands, according to opposite parties Policy bearing number 501- 8130855 is an outcome of a fraud which has been played on opposite party Company. The identity of the Life Assured is disputed and the mere existence of the Assured can also not be ascertained. Even the alleged date of death of the Life assured is disputed. The investigation which was necessitated because of various frauds being committed on the insurance companies and examined the matter in detail and possessed evidences which establish that there is dispute with respect to the identity of the assured and his mere existence. The opposite party was misled to issue the aforesaid policy on the life of the alleged Mr. Jit Singh. Furthermore, the policy was acquired through forged documents and by a well planned criminal conspiracy involving various individuals including the present applicant. This commission has no jurisdiction to entertain the present complaint.  Moreover, the opposite party has appointed the investigator  and he revealed the following facts

1        During investigation the investigator first visited the address i e Akbar Mohalla, Kapurthala Road, Tarn Taran provided by the alleged insured but could not find his residence. The investigator met all nearby area people but no one knows about the insured, his death and his family

2        On the next day the investigator again visited the area and met different people. But again no one knew about the Insured, his death and his family

3        The investigator then called on the number provided and she called the investigator to Ferozepur where there were people present and were ready with the answers. This created considerable doubt as the people were clearly tutored

4        The investigator asked the nominee about her address at Tarn Taran but she could not confirm the same

5        The investigator searched the record of insured in main hospitals of Tarn Taran but no record was found by the name of the insured.

6        The investigator the again investigated in the nearby area of Akbar Mohalla and the bus stand and railway station along with photos of Insured and nominee but no one knew about them.

7        The investigator even visited the nearby cremation ground but no record of the insured was found there also.

8        Various other discrepancies were found.

The opposite party has placed on record report of investigator supported with affidavit Ex. OPs 5/3.  In the report of investigator he concluded that in all our conclusion of our observation that we have not received any record of life insured and nominee on provided address and other nearby area. No one knows about life insured and his death and nominee. He further observed in his report that they visited at nearby all cremation grounds but no record found by the name of life insured. As such, according to opposite party fraud has been committed in the present case upon the opposite party. But on other hands, according to complainant, his case is genuine. Now in the present case, during post investigation, the identity of insured is not established. Now the point involved in the present case, as to whether, Jit Singh life assured has validly taken the insurance policy or not ? Whether,  Jit Singh was residing on the given addresses or not ? Whether, the complainant alongwith others has made fraud with the insurance company or not ?  detailed evidence, cross examination is required and intricate questions of law and facts are involved in the present case. As such , this District Commission  cannot exercise its jurisdiction to decide the intricate questions of law and facts  in a summary manner. Reliance in this regard is placed upon Oriental Insurance Company Ltd. Vs. Munimahesh Patel 2006(IV) CPJ page 1, wherein the Hon'ble Supreme Court has held that :-

“Proceedings before the commission are essentially summary in nature and adjudication of issues which involve disputed factual questions should not be adjudicated. It is to be noted that commission accepted that insured was not a teacher. Complainant raised dispute about genuineness of the documents (i.e. proposal forms) produced by the appellant.”

Their lordships have further held that :-

“The nature of the proceedings before the commission as noted above, are essentially in summary nature. The factual position was required to be established by documents. Commission was required to examine whether in view of the disputed facts it would exercise the jurisdiction. The State Commission was right in its view that the complex factual position requires that the matter should be examined by an appropriate court of Law and not by the Commission.”

The nature of the dispute, in the present complaint, is squarely covered by the law laid down by their lordships of the Hon'ble Supreme Court in the judgment supra. A similar view has been taken by the Hon'ble National Consumer Disputes Redressal Commission in 1(2004) CPJ page 101 wherein it has been held by the Hon'ble National Commission in a revision petition titled as R.D. Papers Ltd. Vs. New India Assurance Co. Ltd. & Ors. in para No.7 of the judgment  which reads as under:-

“After going through the complaint and the written version, it appears to us that the complaint raises complicated questions of facts which cannot be decided by us in our summary jurisdiction. It may be though the amount in this case is in few lacs and when we are receiving complaints involving crores of rupees, but then enormous evidence would be required in the present case especially in respect of allegation of forgery made by the complainant and denied by the Insurance Company.”

5        In view of above discussion, the instant complaint is relegated to the Civil Court for deciding the matter in accordance with law.  Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Commission and due to COVID-19. Copies of the order be furnished to the parties as per rules. File is ordered to be consigned to the record room.

Announced in Open Commission.

18.04.2023