Order by:
Smt.Priti Malhotra, President
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that sister of the complainant (now deceased) had purchased a Life Insurance Policy for an amount of Rs.1.50 Crore from the Opposite Parties, in which, the complainant was nominee. Alleged that at the time of availing the said policy, no details were explained to the DLA besides that the said Plan being a Premium Plan for Policy term of 10 years and for a Sum Assured of Rs. 1,50,00,000/- with annual premium to the tune of Rs.5.00 Lacs for 10 years and a Policy bearing no.0116042619 was issued. During the policy coverage, DLA suffered some problem and was taken to Dr.Amrit Pal Singh Sodhi on 27.09.2021, where she was diagnosed as T2DM/HTN/Right Facial Palsy (Paralysis). Consequently, the treatment was immediately started and a few medical tests were advised. However, the condition of the DLA was not improved, then LA went for second opinion to Dayanand Medical College & Hospital, Ludhiana on 04.10.2021. The DMC & Hospital, Ludhiana after conducting a few checkups in the neurology department confirmed the findings of Dr.Sodhi and advised her some medicines. However, the condition of LA deteriorated within the intervening night of 04.10.2021 and 05.10.2021. Accordingly, she was taken to the hospital of Dr.Sodhi on 05.10.2021. Thereafter administering some medicines and conducting some checkups, the LA was advised to get admitted in the hospital for further treatment. Consequently, the LA got admitted at the Hospital of Dr.Amrit Pal Singh Sodhi. Thereafter, the LA was discharged with follow-up advice from the hospital of Dr.Amrit Pal Singh Sodhi on 09.10.2021. Thereafter, the LA visited the Hospital of Dr. Sodhi for follow-up treatment from 11.10.2021 onwards. But the condition of the LA did not improve and started deteriorating. So, the LA again visited Dr. Sodhi on 08.11.2021. However unfortunately, the LA started feeling very unwell at night intervening 21.11.2021 and 22.11.2021 due to which she was immediately taken to Harbans Nursing Home, Kot-Ise-Khan (Moga) at the early hours of 22.11.2021, where she could not recover and breathed her last on 22.11.2021. Consequently, the complainant raised claim on 01.02.2022 with the Opposite Parties. In pursuance to the said claim the complainant complied with all the requirements and submitted all required documents as required by the Opposite Parties through their authorized representative/Investigation Officer. The said investigation officer had also taken signatures on a few blank papers alongwith forms etc. However, vide letters dated 31.03.2022, the Opposite Parties rejected the claim of complainant. Alleged that LA had also taken another Life Insurance Policy from Bharti Axa Life Insurance Co. The said policy amount has been released after investigation on 06.05.2022. The said repudiation is totally illegal and arbitrary. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Parties may be directed to release the insured amount on account of death of LA alongwith interest @ 9% p.a. from the date of death till its realization for the delay in releasing the said amount.
b) To pay Rs.20,00,000/- as compensation on account of mental torture and agony.
c) To pay Rs.1,65,000/- as litigation expenses.
d) And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.
2. Opposite Parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the complaint filed by the complainant is not maintainable and is liable to be dismissed as the Complainant has attempted to mislead this Commission. Averred that the policy under question i.e. Policy bearing number 0116042619 is an outcome of a fraud which has been played on the Opposite Party Company as in this case the Life Assured Gurmeet Kaur is suspected to be alive and her identity is disputed. Further the details on the Aadhar Card are forged as the Aadhar card number belongs to some other person in the name of Harjit Kaur and the same has been manipulated in the name of the alleged Gurmeet Kaur. The identity of the Alleged Life Assured is disputed and the mere existence of the Assured can also not be ascertained. It has been found that it is case of impersonation and a very calculated conspiracy. Even the death certificate has been procured through fraudulent means. The Opposite Party Company was misled to issue the aforesaid policy on the life of the alleged. Averred further that the Income Tax Returns presented by the LA for the financial years 2019-20 and 202021 along with the PAN were all issued shortly before the issuance of the policy i.e. 11.11.2020 (PAN issued on 28.07.2020 and ITR of 2019-20 was submitted on 17.07.2020). Additionally, it is emphasized that Harbans Nursing Homes, where the LA passed away is notorious in the area for producing such questionable medical documents. 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.
Averred further that the malafide intentions of the complainant and the fraudsters is also clear from the fact inspite of the Opposite Party Company requesting for various documents vide letter dated 8th February, 2022, the same were not provided by the complainant. Averred further that the following was concluded by the investigating agency:-
Through the medical documents we found that the life assured expired on 22/11/2021 at Harband Nursing Homes (Moga) due to cardiac arrest and she suffering from HTN/Type II DM/ Facial Palsy but no onset duration of suffering was mentioned in the medical papers. Further, no past medical papers were found. We strongly suspected that these documents were made hand in glove with the hospital authorities.
Also, the neighbours along with the government authorities didn't recognize the life assured as known as well as told us that the person by the life assured name was never a resident of the area. Hence, we suspect that the family as well as the life assured is planted at the address in order to de-fraud the insurance company and to claim the policy benefits.
Moreover, we also suspect that the shared details on the life assured aadhar card is forged as the adhar number it belongs to someone else's ration details. Hence, we suspect that there could be third party/fraudster involvement in the case to mislead the exact information in order to claim the finds benefits and we also suspect from our past experiences that the life assured could be alive.
Further averred that the proceedings before this Court are essentially summary in nature and adjudication of issues which involve disputed factual questions should not be adjudicated, and hence the present complaint deserves to be dismissed on this ground. This Commission has no jurisdiction to entertain the present complaint. In parawise reply all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.
3. To prove her case, complainant has placed on record copies of documents Ex.C1 to Ex.C13 and her affidavit as Ex.C14.
4. On the other hand, Opposite Parties have placed on record affidavit of Smt.Harshita Chauhan, Assistant Manager-Legal as Ex.OPs1/A alongwith copies of documents Ex.OPs1 to Ex.OPs6.
5. We have heard the ld. counsel for both the parties, gone through the written arguments submitted on behalf of complainant and also gone through the record.
6. Submitted by ld. counsel for the complainant that the deceased policy holder availed a ‘Linked Life Insurance cum savings Regular/Limited/Single Premium Paying Plan’ bearing no.0116042619 from the Opposite Parties for a sum assured of Rs.1,50,00,000/- (Ex.C1). Further submitted that as per death certificate, life assured died on 22.11.2021. Thereafter the death claim was lodged by the complainant being nominee with the Opposite Parties, however, vide letter dated 31.03.2022 (Ex.C11), they declined the claim. Now, the said letter has been challenged by the complainant through this complaint.
7. On the other hand, it is submitted on behalf of the Opposite Parties that after thorough verification of the claim lodged by the complainant, the same has been declined by the Opposite Parties vide letter dated 31.03.2022 on the following reasons:-
“We refer to the proposal form wherein late Mrs. Gurmeet Kaur had given a declaration that he had made true and complete disclosures of all the facts as may be relevant for the acceptability of the proposal form. However during the claim evaluation a mismatch in the identity of the deceased was confirmed by the investigation team.
Therefore we have concluded that late Mrs.Gurmeet Kaur had not provided true answers in the proposal form and documents submitted where fabricated thereby concealing critical information which was material for the Company. Had we known the above mentioned facts at the application stage, we would not have issued the above policy.
In view of concealment of critical information and under the grounds of intent of fraud through impersonation, we regret to inform you that your claim against the subject policy had been declined by the company, hence the total premium paid by Mrs.Gurmeet Kaur shall be refunded in your ICICI Bank account number 356201500400.”
The above said decision of the Opposite Parties is based upon the investigation report sought by them. For the sake of convenience, the details of the investigation report (Ex.OPs4) scanned hereunder:-
8. From above, it is aptly clear that broadly, the Opposite Parties objected and submitted in the written submissions and in the arguments that in this case the life assured Gurmeet Kaur is suspected to be alive and her identity is disputed; that this is a case of impersonation; that details on the Aadhar Card are forged as the Aadhar Card number belongs to some other person by the name of Harjit Kaur and the same has been alleged as manipulated in the name of alleged Gurmeet Kaur; also that Income Tax Returns presented by the life assured for the financial year 2019-20 and 2020-21 and PAN number was issued shortly before the issuance of the policy i.e. PAN was issued on 28.07.2020 and ITR of 2019-20 was submitted on 17.07.2020. Opposite Parties further claimed that the issue involved needs through probe and needs to be relegated to the appropriate court of law.
9. Considering the objections/submissions raised by the Opposite Parties and also considering all the submissions of the complainant too, we have thoroughly perused the record with special reference to the investigation report as scanned above and also the claim decline letter dated 31.03.2022 (Ex.C11). After going through the record meticulously, we are convinced with the submissions of the Opposite Parties, as we found various discrepancies in the record itself. Firstly, the complainant in her complaint failed to clarify the objections raised by the Opposite Parties qua Aadhar card of the deceased policy holder, which the Opposite Parties claimed to be manipulated. It has not been explained by counsel for the complainant that how come the Aadhar number of one Harjit Kaur been shown in the name of deceased policy holder. Also there is discrepancy qua the occupation and income of the deceased policy holder. The perusal of proposal form (Ex.OPs1) reveals that occupation of the policy holder is mentioned as ‘boutique’, but there is no document on record showing that policy holder was running any boutique in her name. Also we have gone through the copies of income tax returns so placed on record (attached with Ex.OPs4), where in the income tax return for the year, 2019-20 shows the income of Rs.3,96,070/- and in the said return in Exempt Income ‘Agriculture income is mentioned as Rs.12,62,720/- i.e. when the policy in question has been obtained. Strangely, in the Income Tax Return for the year 2020-21 income of the policy holder is shown as Rs.4,84,110/- and there is no reference of any income shown from Agriculture, as in the earlier return, it was shown as Rs.12,62,720/-. There is no clarification regarding this discrepancy. The complainant has also failed to place on record exact date of issuance of PAN Card in the name of deceased policy holder, as only front side photocopy of the PAN Card is placed on record by the Opposite Parties (attached with Ex.OPs4), which fortifies the objection raised by the Opposite Parties that the same was obtained only few months back from the date of obtaining the policy in question i.e. on 28.07.2020 and the policy was issued on 11.11.2020.
10. It is pertinent to highlight that it has been noticed that there is manipulation done in the medical record so placed on record by the complainant and also there is distortion of facts as averred in the complaint vis-a-vis the documents placed on record by the complainant. We have perused the OPD slip Ex.C2, Biochemistry Report Ex.C3 and OPD slip of DMC & Hospital, Ludhiana Ex.C4 revealing that there is manipulation been done with regard to the ‘age’ of deceased policy holder for the reasons best known to the complainant.
Further in the proposal form (Ex.OPs1) the weight of Gurmeet Kaur (policy holder) is mentioned as 55 kgs, whereas in the OPD slip of Dr.Amrit Pal Singh Sodhi (Ex.C2) the weight of policy holder is mentioned as 79.9 kgs. Further it has been observed that the complainant in her complaint alleged that deceased policy holder firstly approached Dr.Amrit Pal Singh Sodhi on 27.09.2021. Thereafter she went to DMC & Hospital, Ludhiana on 04.10.2021, thereafter again she was taken to hospital of Dr.Amrit Pal Singh Sodhi on 05.10.2021 and discharged from the hospital on 09.10.2021. But to our utter surprise, in the OPD slip of DMC & Hospital, Ludhiana (Ex.C4) hospitalization period of Gurmeet Kaur (deceased policy holder) is shown as 07.10.2021 and not 04.10.2021 as has been averred in the complaint. Again to our astonishment discharge summary of Dr.Amritpal Singh Sodhi attached with Ex.C5 the hospitalization period of Gurmeet Kaur is shown as 05.10.2021 to 09.10.2021, which creates doubt about the visit of the policy holder at DMC & Hospital, Ludhiana on 07.10.2021, as complainant has placed on record the medicine receipts of each date when the policy holder remained admitted in hospital of Dr.Amritpal Singh Sodhi i.e. dated 5, 6, 7, 8 and 09.10.2021. So, the submission of the complainant that on 7th of October, the policy holder was taken to DMC & Hospital, Ludhiana is apparently wrong for the simple reason that how come a person could be present at two places at one point of time. Further there is mismatch of photo of deceased policy holder in proposal form as well as on PAN Card.
11. From the above discussion, we are of the concerned view that in the present complaint, complicated questions of facts are involved which require evidence at length and thorough probe into the matter is required to be made and as such, the complaint cannot be decided in a summary manner, therefore this Commission has no jurisdiction in the light of the judgement delivered by Hon’ble Supreme Court in which it has been clearly held that where there are complicated questions of facts/law which require lengthy trial and evidence to be led by both the parties and also to provide opportunity to cross examine the witnesses, then such type of the complaints should not be entertained by the Commission, rather should be relegated to the Civil Courts.
From the appreciation of the facts and circumstances of the case, it becomes evident that examination and cross examination of the witnesses is required and as the proceedings before this Commission are summary in nature, thus this Commission cannot go deep into the matter or allow the examination and cross examination of numerous witnesses or production of voluminous documents. 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 judgement (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 judgement 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.”
Further whereas, the procedure before this Commission is of summary in nature and the evidence of expert and cross-examination of alleged witnesses cannot be made in this Commission. Hon’ble National Consumer Disputes Redressal Commission, New Delhi observed in the citation 2014(1)CLT, paged 481 titled as M/s Heights Trade (P) Ltd. Vs UCO Bank as under:-
Consumer Protection Act, 1986, Section 13-Summary Procedure. Complicated question. Jurisdiction-Intricate and complicated questions involved in the case. It would be difficult to decide the case on mere documents. The evidence of Experts and Record have to be looked into. These questions must be discussed by an appropriate forum or civil court. The Consumer Commission must refrain from arrogating those powers which it does not possess.
12. Keeping in view the aforesaid facts and circumstances of the case and being guided by the law on the subject, we refrain to decide the present complaint and the present complaint is hereby disposed of with liberty to complainant to approach the appropriate court of law for the redressal of her grievances and time spent before this District Commission shall stand excluded under Section 14 of the Limitation Act in the light of the judgment of the Hon'ble Supreme Court in case titled 'Lakshmi Engineering Works vs PSG Industrial Institute reported in 1995(3) SCC 583'. However, keeping in view the peculiar circumstances of the case, the parties are left to bear their own costs. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced in Open Commission
