PER:

Nidhi Verma, Member

1        The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 34, 35, 36 and 38 against the opposite party on the allegations that the opposite party through its officials and agents have approached the complainant, the deceased life assured and his family and gave lucrative offers for having a life insurance policy i.e. “Bharti Axa Life Super Endowment Plan” and had told about the above policy to the complainant, the deceased and other family members and they were attracted to the offers made by the opposite party/ it’s agents. The family members of the complainant had proposed to assure the life of Bachittar Singh @ Bachitar Singh son of Jagir Singh vide the life insurance policy of the company that is Bharti Axa Life Super Endowment Plan and the company has issued the policy in favour of the deceased/ applicant Bachittar Singh @ Bachitar Singh vide policy No. 502-9644001 and the said policy was issued in the year 2021 and the basic premium yearly was fixed of Rs. 21,720.00 Paise and the complainant has paid the first premium including taxes i.e. Rs. 22,999.54 Paise  of the policy vide invoice bearing No. PN2021SL00023304 dated 11.2.2021. The basic sum assured was fixed of Rs. 3,27,504/- and the death claim was fixed as Rs. 6,55,008/-  and the complainant is nominee of the policy. Afterwards, unluckily the applicant Bachittar Singh @ Bachitar Singh died a natural death on 2.3.2021 at his residence i.e. village Padhri Khurd District Tarn Taran. The complainant had given the required information to the company regarding the death of the Bachittar Singh alias Bachitar Singh for obtaining the amount of sum assured on death under the policy. All the requisite details that is death certificate, forms and information were provided to the officials of the opposite party i.e. company and the officials had assured the complainant that the death claim amount will be provided soon. Later on the company kept mum for several months since the death of the applicant Bachhitar Singh @ Bachitar Singh and thereafter just in order to save their skin and money and above all to decline the genuine claim of the complainant, repudiated the claim in a highly arbitrary manner vide it’s correspondence dated 30.9.2021 on the basis of alleged incomplete,  false and self interpreted grounds of impersonation, health issues and others alleged documents/ submissions which had never seen in light of day and were never within the knowledge of the complainant as well as of the deceased at the time of purchasing of the policy. The claim was repudiated without showing any of the alleged documents to the complainant. All the alleged facts mentioned by the company i.e. opposite party in the repudiation letter dated 30.9.2021 regarding the deceased life assured are false and based upon the baseless and frivolous documents, if any would produce by the company later on. The deceased life assured had given all the correct facts before purchasing of the policy but the agents of the company have got the signature of the applicant on all the documents without dictating the contents of the clauses to the deceased as such there is no fault on part of the applicant in this respect. No alleged terms and conditions of the policy have ever been dictated to the life assured and the complainant on the basis of which the claim of the complainant is repudiated. The deceased was not suffered with any of the alleged disease. The identity of the life assured was verified by the officials of the company and the authorized doctor of the insurance company had examined the insured, assessed the fitness and after complete satisfaction, then the policy was being issued and if the deceased life insured could have been suffered with any kind of serious disease, then it must came to the knowledge of the insurance company at that time. At the time of issuing of the policy, no alleged terms and conditions have been ever dictated/ explained to the applicant/ her representatives. The complainant has prayed that the opposite party be directed to pay the total minimum death benefit under the policy i.e. the sum of Rs. 6,55,008/- on account of loss and compensation with interest to the complainant. The opposite party may also be directed to compensate the complainant to the tune of Rs. 20,000/- and Rs. 10,000/- as litigation expense.  Alongwith the complaint, the complainant has placed on record affidavit of complainant Ex. C-1, Self attested copy of welcome letter Ex. C-2, Self attested copy of proposal form Ex. C-3, Self attested copy of declaration form Ex. C-4, Self attested copy of Premium fixation Slip Ex. C-5, Self attested copy of Illustration Benefits Ex. C-6, Self attested copy of Premium receipt and policy schedule Ex. C-7, Self attested copy of Death certificate Ex. C-8, Self attested copy of voter list Ex. C-9, Self attested copy of Voter ID Card Ex. C-10, Self attested copy of Affidavit Ex. C-11, Self attested copy of Adhar card Ex. C-12, Self attested copy of repudiation letter dated 30.9.2021 Ex. C-13, Self attested copy of Adhar Card of complainant Ex. C-14.

2        Notice of this complaint was sent to the opposite party and opposite party 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 the Commission. In fact the Complainant has suppressed material facts from this Commission and as such the complaint is liable to be dismissed.  The policy under question i.e. Policy bearing number 502- 9644001 is an outcome of a fraud which has been played on the opposite party Company. The present policy was an outcome of a fraud as the present case is case of impersonation and tampering of documents at the time of taking the policy. The identity of the Life Assured is disputed and the mere existence of the Assured can also not be ascertained. Even the alleged death of the Life assured is seems to be conspiracy in order to cheat the company. 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. It has been found that it is case of impersonation or a very calculated conspiracy. The opposite party Company was misled to issue the aforesaid policy on the life of the alleged Bachittar Singh. Furthermore, the policy was acquired through forged documents and by a well planned criminal conspiracy involving various individuals including the present complainant and as such the present application is not maintainable before this commission.  The case title of the present complaint is itself creates various doubts about the identities of the Complainant and the alleged life assured in both names an alias has been mentioned which was not the case during the proposal stage or later on also. This is relevant as the investigations have revealed impersonation and tampering. Furthermore this commission has no jurisdiction to entertain the present complaint. In the instant case the proposal form and other documents purportedly bearing signature of the life to be insured were fraudulently submitted at the proposal stage and the existence and death of the Life assured could not be established. In the present case there are serious issues of Impersonation, 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. It is clear from the facts of the case that the matter in question involves complicated questions of facts and law as well as voluminous evidence, which can only be dealt with by a civil court. Furthermore, the opposite party company is contemplating criminal proceedings against the applicant and other persons for committing fraud and forgery.  In the instant case there has been a deliberate attempt to defraud the opposite party Company of a huge sum for which the opposite party Company is contemplating to launch appropriate criminal proceedings against the complainant, agent and other fraudsters 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 in other genuine policy holders. 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 along with the claim The submission of medical documents reasoning the cause of death have not been provided. The idea of the fraudsters to directly file this present complaint was to avoid any thorough investigation into the matter. The complainant has with malafide and dishonest intention has twisted and distorted the same to suit his 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 opposite party 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. The Company has received various claims from location Taran Tarn and neighboring areas, wherein

a)       the LA mysteriously dies within One month 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 assured are also disputed

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

e)       There is tampering, forgery and fabrication of documents

In the present case too, the claim was received from and the above mentioned nexus is clearly and blatantly evident. The opposite party got investigation done from Investigation Agency and the following was revealed:

-Case of impersonation. LA died on 02-03-2021. Death Happened within 26 Days of issuance of the policy.

- The Aadhar card shared at the time of proposal differs from the Live Photo which has been procured at investigation stage, this clearly reflects that the Aadhar Card has been tampered by LA at the proposal stage and the actual identity has not been disclosed to the Company: -

- Neighbors said that LA was living in Amritsar after his marriage

-Vicinity check: He was suffering from Tuberculosis and Sugar for a very long time and was under treatment.

- Negus is involved and the true identity is disputed.

- Case of impersonation and tampering of documents.

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 money from the answering opposite party, and hence the application deserves to be dismissed in limine. The application has been filed with ulterior motive and malafide intention, to cause harassment and prejudice to the opposite party, which is a company of long standing and high repute, and to extract money from it without just cause or valid reason. The opposite party company has been induced to issue the policy vide a very well planned conspiracy. The subject matter for the above policy itself is proved to be initiated by fraudulent act, and therefore, the said policy is declared void by the opposite party Company, and consequently, no benefit or amount under the said policy becomes payable, as the applicant is guilty of suggesto vari supresso falsi. This Commission has no jurisdiction to entertain the present application. The applicant has failed to demonstrate any deficiency in service on the party of the opposite party. In the present case, the opposite party has strictly acted as per the terms and conditions of the policy contract. That 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. Thus, the words in an insurance contract must be given paramount importance and interpreted as expressed without any addition, deletion or substitution. The commission cannot pass any order in contravention to the terms and conditions of the policy contract.  The complainant has not acted in god faith with respect to subject of this complaint and has approached this commission with unclean hands, whereas it is a settled legal preposition that “One who seeks equity must come with clean hands” Additionally, the complainant is merely the nominee under the subject policy and not the actual beneficiary of the policy proceeds. However, it is a settled principle of law that only a beneficiary falls under the definition of Consumer within the confines of the Consumer Protection Act 1986. In the instant case when the post issuance investigation was conducted, it was also found that some documents submitted at the time of taking the policy were fabricated documents. It is settled principle of law that if any person signs a document, it is presumed that he/ she has signed the same after reading and understanding it properly. It is also settled principle of law that person who fills up anything on a signed document has status of ‘amanuensis’ only and cannot be treated as author of document. At the time of scribing (without admitting) the person who scribes (amanuensis) is treated as representative of person who has signed document and not the representative of the company, thus after signing the document the person cannot release from signed document and lead anything which is contrary to terms stated in writing. The present complaint is liable to be dismissed on the ground of mis-joinder and non joinder of parties. No agent can be assumed to have authority from the insurer to write the answer in the proposal form. If an agent nevertheless does that, he becomes merely the amanuensis of the insured and his knowledge of the untruth or inaccuracy of any statement contained in the proposal form does not become the knowledge of the insurer.  The opposite party has denied the other contents of the complaint and prayed for dismissal of the same. Alongwith the written version, the opposite party has placed on record affidavit of Mitesh Pabari, working as Manager Ex. OP1/A alongwith documents Ex. OP1/1 to Ex. OP-1/5.

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

4        In the present complaint Bachhitar Singh son of Jagir Singh purchased the policy number 502-964-4001 from opposite party and the said policy was issued in the year 2021 and premium paid for the same Rs.22,999.54/- and death claim was fixed as Rs.6,55,008/- . On dated 2/3/2021 Bachhitar Singh died a natural death due to heart attack at his residence. The complainant had given the required information to the company regarding the death of the applicant Bachhitar Singh for obtaining the amount of sum assured on death under the policy, all the required detail that is death certificate ,forms and information were provided to the official of the opposite party . On dated 30.09.2021 O.P repudiated the claim of the complainant. The complainant had made number of requests regarding reconsideration of death claim of her husband but the O.P has done nothing for providing justice to the complainant.

5        O.P stated in their written version that the identity of the life assured is disputed and the mere existence of the assured can also not be ascertained. Even the alleged death of the life assured is seems to be conspiracy in order to cheat the company and  the policy was acquired through forged documents. The company has received various claims from location Tarn Taran  and neighbouring areas where in:-

•  A life insured mysteriously dies within one month from the insurance of the policy.
•  It is noticed that the claimants do not provide any medical certificate from treating doctor.
•  The identities of the assured are disputed.
•  Even the dead bodies get buried in the absence of any doctor’s certifying the death or even when no postmortem is done to ascertain the cause of death.
•  There is tempering forgery and fabrication of documents.

6        In the present case the company got investigation done from investigation agency and the following was revealed:-

•  LA died on 2^nd March 2021 that happened within 26 days of insurance of the policy.
•  The adhar card shared at the time of proposal differs from the live photo which has been procured at investigation stage.
•  Neighbours said that LA was living in Amritsar after his marriage.
•  He was suffering from tuberculosis and sugar for a long time and was under treatment.
•  Negus is involved and the true identity is disputed.
•  Case of impersonation and tampering of documents.

 All the above points clearly speak of the ill intent and motive behind taking the insurance policy. The subject matter for the above policy itself is proved to be initiated by fraudulent act and therefore the said policy is declared void by the company and consequently, no benefit or amount under the said policy becomes payable.

7        As a result of the above discussion we are of the considered view that, as per repudiation  letter (Ex.C-13) OP rejected the claim of the complainant on :-

• An attempt of impersonation and deliberate attempt to defraud the company.
• LA prior to his death was not in good health which establishes false health details were given in the proposal for this insurance policy.

8        To prove their point OP has failed to place on records any evidence related to medical history of the LA , merely gathering information from neighbours regarding the health of the LA by investigator that LA was suffering from tuberculosis and sugar from past few years and having treatment is not justified. Further, OP has failed to provide any medical history of the LA from any hospital. No such record of any doctor has been placed on record to show that the complainant was patient of tuberculosis and sugar for a long time and the opposite party has not placed on record affidavit of any doctor to establish and prove the fact that the deceased was suffering from the alleged disease.  In this regard, a reference can be made to the judgment of the Hon'ble National Commission in Revision Petition No. 200 of 2007 "Mr. Satinder Singh versus National Insurance Co. Ltd." decided on 24.1.2011 wherein it has been observed that "recording of history of patient in the above stated manner does not become a substantiate piece of evidence and convincing evidence be brought on record that complainant was aware of preexisting disease." Further, it has been observed by the Hon'ble National Commission in the III 2014 CPJ 340 (NC) "New India Assurance Company Limited through its duly Constituted Attorney, Manager versus Rakesh Kumar" that people can live months/years without knowing the disease and it is diagnosed accidentally after routine checkup and on that ground repudiation is not justified. Further it has been observed by the Hon'ble National Commission in its judgment IV (2008) CPJ 89 (NC) "Life Insurance Corporation of India & Ors. Versus Kunari Devi" that history recorded in the hospital bed head ticket is not to be taken as evidence as Doctor recording history not examined and suppression of disease not proved. In the present case investigator mentioned in his investigation report that “ they visited various hospitals of the area but no records found on the name of LA”. Then how can they repudiate the claim of the complainant by merely saying that LA prior to his death was not in good health which establishes false health details were given in the proposal for this insurance policy.

9        O.P repudiated the claim on basis of deliberate attempt to defraud the company and forged documents, regarding this again O.P failed to provide any evidence on record to stand their point. Investigator found from their investigation from neighbours that “LA was resident of village, but he was living in Amritsar after his marriage”, which seems no fraudulent on the part of LA, as people normally move from their permanent address merely for earning more or for some other matter. Regarding  documents complainant placed on record death certificate (Ex.C8), voter list of LA area(Ex.C 9), LA voter card(Ex.C10), complainant affidavit (Ex.C 11), LA adhaar card (Ex.C12) complainant adhar card (Ex.C14) which itself proves that there is no forgery ,tempering and fabrication of documents. Further, investigator mentioned in his report regarding online check status for LA adhar card as ‘genuine’. Now if we go through the photo of LA mismatched with aadhar card and live photo. Usually there is difference between the photograph on Adhar cards and live photos. Moreover with the passage of time, it usually changed the appearance / face than the earlier clicked photos.  The change of photo on Adhar card and live photo is not the genuine reason for rejecting the claim.

10      However, OP failed to place on record any affidavit of the neighbours from whom they collect the information regarding LA health. Moreover,  the whole of the case of the opposite party revolves around the survey report Ex/Annexure 1/3. But to prove the above said report of surveyor, the opposite party has not placed on record the affidavit of surveyor. In the absence of which no evidentiary value can be made on the report submitted by the surveyor. Reliance in this connection has been placed upon Manikant Vs. New India Assurance Co.Ltd. 1(2012) CPJ 88 (NC) of the Hon’ble National Commission wherein it has been held that the surveyor did not appear in court and subject himself to cross examination nor was any affidavit filed by him to prove his report . Producing a document in court does not by itself constitute proving the document. It has to be backed by credible evidence. In the instant case, no evidence was led to prove the surveyor’s report in the absence of which the surveyor’s report has little evidentiary value.   

11      Furthermore, It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of DharmendraGoel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.UshaYadav& Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.        The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

12      In light of the above discussion, the complaint succeeds and the same is hereby allowed with costs in favour of the complainant and against the Opposite Party. The opposite Party is directed to make the payment of Rs. 6,55,008/-  to the complainant. The complainant has been harassed by the opposite party unnecessarily for a long time. The complainant is also entitled to Rs. 15,000/- as compensation on account of harassment and mental agony and Rs 7,500/- as litigation expenses. Opposite Party is directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation.  Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Commission. Copy of order be supplied to the parties free of costs as per rules. File be consigned to record room.

Announced in Open Commission

30.05.2024