PER:

Charanjit Singh, President

1        The complainants have filed the present complaint by invoking the provisions of Consumer Protection Act under Section 34, 35 against the opposite parties on the allegations that wife of complainant No. 1 and mother of complainant No. 2 Mrs. Sharanpreet Kaur was insured with O.Ps. under the Policy Plan ICICI Pru iProtect Smart vide Policy No. A3692683 for sum assured Rs. 1,00,00,000/-plus accidental death benefit of Rs. 10,00,000/- since 2.11.2021 against payment of yearly premium of Rs. 77,453/-.  Copy of policy document alongwith receipt of the same is Ex. C-1. The said policy was issued by O.Ps. after taking complete note of health status of the insured as well as after taking in to consideration as the documentary evidence of the of the insured with regard to her address, financial status, income as well as income tax returns and other documents of M/S.PANNU MOBILE ZONE PVT.LTD. company where she was director & 50% shareholder as well as was having her ownership/ 50% partnership in PANNU MOBILE ZONE partnership firm. Since the life assured died on 13.10.2022 due to accidental injuries, copy of death certificate is Ex.C-2, Complainant No.1 being nominee in the said policy and her class one legal heir along with complainant No.2 being minor son born out of the wed lock of deceased insured as well as complainant No.1, both are covered under definition of ‘consumer’ to invoke jurisdiction of this Commission for arbitrary and illegal denial of the death claim of the deceased insured arisen under the policy above mentioned. Complainants are the only class one legal heirs of the deceased insured. The present complaint is being filed by complainant No.1 on behalf of complainant No.2 as well, being his father and natural guardian, having no adverse interest against him. Late Mrs.Sharanpreet Kaur met with a road accident with a truck on 26.09.2022 near Kharar, Distt. Mohali in the late evening while being passenger in the car being driven by complainant No.1. Complainant No.1 after the accident informed the Police at their helpline No.112 immediately. Printout of SMS received from the POLICE with ref.No.1049308 on 26.09.2022 at 11.01.PM is Ex.C-3.  Since the insured became unconscious in the accident for about 15 minutes, and had BLEEDING FROM NOSE, EAR and BLEEDING PER VAGINUM, she was taken to Shalby Multispecialty Hospital, Mohali where she was admitted for evacuation and further management and investigations for her accidental injuries. The hospital authorities also sent message to area police station reporting admission of the patient with accidental injuries the same very night, copy of MLC Information Form sent by the Hospital to Police Authorities is Ex.C-4. Complainant No.1 also suffered from minor injuries in the accident for which he got first aid from this hospital as well. Since the vehicle of complainant which met with an accident was insured with ICICI Lombard General Insurance vide Insurance Policy, a sister concern of O.Ps, and also the family of complainant was having Mediclaim Insurance Policy No.40151/IDOPD/212242000/01/000 during relevant times, ICICI Lombard General Insurance gave authorization for cashless treatment of the patient insured on 27.09.2022 itself, copy of which is Ex.C-5, after TPA desk of the hospital requested for cashless treatment of the insured. Since she was to be kept under observation and was advised rest for 1 week and follow-up after 5 days, thus she was discharged from the hospital on 29.09.2022 on DOMICILLIARY TREATMENT. Copy of discharge summary dated 29.09.2022 is Ex.C-6. On 6.10.2022, i.e. after one week, she was re-admitted in the same hospital with complaint at that time of DIZZINESS, CONVULSIONS, UNCONCIOUSNESS LASTING 3-4 MINUTES ABOUT ½ HR. BACK, SWEATING, COLD EXTREMITIES ½ HR BACK, BLEEDING PV FOR THE LAST 2-3 DAYS, HISTORY OF SAME EPISODES TWICE 2 DAYS BACK. During the course of the patient/ insured in the hospital, she had cardiac arrest on 7.10.2022. She was revived from that and shifted to ICU. But MRI done on 10.10.2022 showed acute hypoxic brain injury which resulted into POOR PROGNOSIS. Weaning off trial of ventilator and other life support systems failed indicating brain death. Accordingly, in that medical condition where the patient was not going to survive  as narrated by the treating doctors, LAMA discharge was taken from the hospital, copy of LAMA Summary is Ex.C-7. Copy of Authorization letter dated 13.10.2022 for the Treatment Guarantee of Payment given by ICICI Lombard to the hospital dated 13.10.2022 after investigation of the entire record is Ex.C-8, accordingly whole of the treatment of the patient was given cashless. Mrs.Sharanpreet Kaur died the same day within small time after LAMA discharge from the hospital after her ventilator was removed/ weaned off after shifting her from hospital at the place where she was residing at that time. After getting free from death rituals of the deceased insured/ wife of complainant No.1, he approached police authorities to find out status of police report of the accident. The Police authorities filed General Diary dated 02.11.2022 for the incidence, copy of which is Ex.C-9. After it, complainant No.1 approached O.P. also for the claim under the policy, which was assigned Claim id UDI199217. All requisite documents as and when demanded by O.P.s, whether relevant or irrelevant were supplied to them. The Medical Attendant’/ Hospital Certificate with regard to the treatment submitted is Ex.C-10, and copy of FIR lodged on the asking of O.P.s is Ex.C-11 which was registered by police authorities on 28.03.2023. In-between the claim of vehicle of the complainant which also was damaged badly, and was assigned Claim No.MOT12884073 by ICICI Lombard General Insurance Company was settled for Rs 1,86,781/- and paid and message was received by complainant No.1 on 19.01.2023, copy of print out of which is Ex.C-12. Since O.Ps. were not settling the genuine claim of the complainants, they were approached repeatedly. Thus vide letter dated 24.11.2022 (Copy is Ex.C-13), 26.04.2023 (Copy is Ex.C-14) as well as 30.05.2023, (copy of which is Ex.C-15), it was informed that the claim was currently under process, and that in case of delayed payment, interest is applicable/payable as per IRDA Guidelines. However, to the dismay and shock of the complainant No.1, O.Ps. filed complaint with Chandigarh Police dated 27.06.2023 against complainant No.1 for Forgery/ Cheating and Fraud with regard to the Policy and Claim thereon in question, clinching it with some other claims which had been repudiated by O.Ps. in the past. The Police thoroughly investigated the complaint and vide order/ report dated 7.08.2023 (copy of which has been obtained by complainant No.1 under RTI), gave finding: “Matter is found to be related to non-sanctioning of insurance claim by insurance com complainant company. No cognizable offence has been found made out. Hence, the attached complaint may please be filed.” In that very report, the Police Authorities held that in the claims with which name of complainant No.1 had been arbitrarily associated by O.P.s, in those claims’ documents produced could not be proved to be forged documents as well. Police Report dated 7.08.2023 which includes complaint of O.Ps. against complainant No.1 is Ex.C-16. This report of Police also contained CLAIM INSVESTIGATION REPORT submitted by O.Ps with Police for the purpose of investigation which itself states at POINT/CLAUSE “G” of the report “This claim appears to be Genuine. LA passed away in a Road Accident, General Diary, Accident Spot Video, LA Summary, Discharge Summary and Treatment papers procured and enclosed herewith. No past medical history of LA found in this case.” Copy of the CLAIM INVESTIGATION REPORT is Ex.C-17. On the asking of investigator of O.P.s, complainant No.1 approached Police Authorities at P.S.Suhana within whose jurisdiction accident took place to verify facts with regard to information of the accident received with the Police Authorities from various sources on the night of accident itself. Police Authorities issued Docket/ Memo with this regard along with the documents verifying the immediate information received by the Police Authorities through Control Room as well as from the Hospital and action taken thereon with attested copies of the docket/MLC Information Form received in the Police Station, copies of which are Exh.C-18. Copies of these documents were supplied to the investigator of O.P.s there and then during the course of investigation.  In the meantime, without waiting for the result of the Police Complaint made by O.Ps, and even ignoring their own Claim Investigation Report, vide letter dated 21.07.2023, copy of which is Ex.C-19, O.Ps repudiated the genuine claim of the complainants on the ground that 

a) General Diary has been registered by the Police on November 02, 2022 which only mentions about the road accident of the life assured which took place on Sep.27, 2022.

b) Even though the General Diary was lodged after 20 days of the death of the Life Assured there is no mention of the death in this record.

c) First information report is to be lodged immediately on the occurrence of the accident. However, in the present case, it was lodged by you on March 28,2023 i.e. 6 months after the occurrence of the accident and 5 months after death of the Life Assured.

d) Further no reason or confirmation has been provided by you regarding the delay in registering the FIR though specific provision for the same has been sought in the FIR.

e) It is also submitted that, neither you have submitted a Medico-legal cause of death certificate, nor you have submitted any certificate from the doctor who has declared the life assured dead despite the same being specifically sought by the company.

Along with this, O.P.s also challenged occupation and annual income of the insured.

Further, O.Ps credited the premium amount of the policy with interest Rs 91,395/- in the account of the complainant No.1, particulars of which were furnished to O.Ps for the purpose of settlement of the claim, and not in the account out of which the deceased insured paid the premium. Copy of the advice/ e-receipt of the amount received as refund of premium on 24.07.2023 is Ex.C-20.  After receipt of arbitrary repudiation letter, complainant No.1 filed complaint/ review with Grievance Redressal Committee of O.P.s against illegal repudiation on 27.07.2023, copy of which is Ex.C-21. Till date no reply/ response has been received by complainants from their Grievance Redressal Committee though it is more than 5 months now when the same was filed. In the said review request, complainant No.1 gave detail explanation of all the arbitrary issues raised by O.Ps. for repudiating the genuine claim, but O.P.s are keeping mum over the issue. In the meantime, vide letter dated 12.09.2023, Copy of which is Ex.C-22, ICICI Lombard General Insurance Company made payment of the Personal Accident Claim of Rs 15,00,000/- (Rs.Fifteen Lac) under Policy No.3001/253494422/00/000  as Claim No.MOT138288234 with regard to the death of the deceased Mrs.Sharanpreet Kaur.  For the above-mentioned deficient acts of O.P.s of declining the genuine claim on flimsy grounds, even ignoring the findings of their own investigators and then not even responding to the review filed before their own grievance channel, and taking no cognizance of the findings of Police Investigation on their complaint given in favour of the complainants stating the claim being genuine, and instead of making payment of the claim amount returning the premium of the policy just to get rid of the liability of the claim amount; complainants are suffering harassment, mental agony, and financial loss for which O.P.s are liable to compensate the complainant. Even the acts of O.P.s lack human touch as well, coffering upon the rights of motherless complainant No.2. Complainants suffered damage to their reputation as well due to false complaint filed by O.P.s with police with the allegation of procuring insurance policy by fraud and cheating which were repelled by the police authorities in their detailed investigations. For such arbitrary, illegal and deficient and glaring acts of O.P.s, they are liable to pay exemplary costs and compensation as well in addition to the claim amount. The complainants are permanent residents of District Tarn Taran, as is mentioned in the policy document itself, and further since the premium amount of the policy was Rs 77,453/-, therefore, the matter is well within territorial as well as pecuniary jurisdiction of this Hon’ble Commission and the complainant prayed that O.P.s be directed to remove the deficiency in service and 

1. Compensate the complainants by allowing claim amount of Rs 1,10,00,000/- i.e. One Crore and Ten Lac (i.e. Rs 1,00,00,000/- for death claim and Rs 10,00,000/- as accidental benefit claim) with interest @18% p.a. from the date of death i.e. 13.10.2023 till payment;
2. Pay further compensation of Rs.10,00,000/= (Rupees Ten Lac) as punitive damages for acute harassment as well as mental agony meted by complainants at the hands of O.P.s and financial loss as well;
3. Pay Cost of complaint to the tune of Rs.1,00,000/= (Rupees One Lac),

2        Notice of this complaint was sent to the opposite party and opposite party appeared through counsel and filed written version (though without any supporting affidavit or documents mentioned as Annexures in the written version but were not part of it) by interalia pleadings that there is no pecuniary jurisdiction of this commission as the total sum assured and the prayer is more than the jurisdiction of this commission. Therefore, the jurisdiction of this commission cannot be invoked. Violation of Principle of utmost good faith. An insurance policy works on the principle of uberrima fides which means utmost good faith. Under an insurance policy, the proposer/ policy holder is bound to give true and correct information in proposal form without withholding any material information from the insurance company. The person seeking insurance knows all the facts which materially affect the risk on his or her life. The person seeking insurance is the only person having full knowledge and he is under the solemn obligation to make a full and honest disclosure of all the facts to the insurer at the time of insurance proposal. The person seeking insurance is expected to maintain a high and rigorous standard of good faith while obtaining insurance policy on his or her life as the insurer cannot have any information or knowledge on its own about the proposer/ DLA of the policy. In the present case, the subject policy i.e. policy No. A3692683 was issued on 2.11.2021 and thereafter the opposite party received a claimant statement form (death claims) from the complainant stating that the LA died on 13.10.2022 (within one year from the date of insurance of the policy). Since the death was within 3 years from issuance of the subject policy the same fell under the category of an ‘early claim’. Thus to verify the genuineness and veracity of the disputed claim as per Section 45 of the Insurance Act, 1938, the opposite party conducted an investigation. During the investigation, it was found that the LA had misrepresented her occupation and income. At the time of issuance, in the proposal form the LA had stated that she was a “Salaried Employee and Graduate” with annual income of Rs. 7,00,000/- however, during investigation it was revealed that the actual income of the LA was Rs. 3,00,000/- only and she was actually working in mobile shop. Thus it was clear that the complainant had attempted to defraud the opposite party, thus making the subject policy null and void. Hence, the opposite party rightly declared the subject policy null and void vide letter dated 21.7.2023 and the same was done in due compliance of provision of Section 45 of Insurance Act, which had clearly been reproduced in the last page of the proposals in order to keep the proper clearly aware about the applicable law. The complainant has committed fraud. The present case is a perfect example of a very well-planned 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 in to

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

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

Policy under question i.e. Policy bearing No. A3692683 is an outcome of a fraud which has been played on the opposite party company. The opposite party company was misled to issue the aforesaid policy on life of the Life Assured by fraudulent acts, suppression of material facts and misstatement. Thus the LA and the complainant have committed grave fraud against the opposite party company and is now trying to gain illegal advantages. Insurance fraud has been on a rise across the Country and has taken a form of organized crime directed against the insurance industry. Organized gangs, grooming nation wise for the last a few years, are looting via fraudulent means, crores of rupees from the insurance companies in both private sector and from Government of India undertakings. The fraud is being perpetrated by individual and/or entities inconnivance with policy holders, beneficiaries, vendors, career criminals etc. Various judicial and police authorities in multiple states have taken a note of the same and have directed enquiries and investigations in to the rampant problem of insurance fraud. As an insurance company the opposite party has been observing that the has been a steady increase in fraudulent claims being filed from various regions of Punjab more particularly the regions of Mohali/ Tarn Taran.  Further during investigation in the present case, the following suspicious points were also revealed.

1. The company has investigated multiple cases from Mohali and adjoining regions and has prima facie observed involvement of two individuals:-

1. Lakhwinder Singh son of Jarnail Singh r/o 1319/21 Phse 11 Sector 65, S.A.S Nagar Mohali- 160062 having Phone No. 9878138906
2. Sweety Arora D/o Satpal Arora r/o 1319/21 Phase 11 Sector 65, S.A.S. Nagar Moahli-160062 having phone No. 9041569446

For having a leading role in issuance of fraudulent polices and death claims being raised associated with the said Policies.

(B)     The said people at the center of death claims associated with 4 polices held by 3 persons that are

          (i)      Gurpreet Singh (Policy No. 84655693 and 84940691)

          (ii)     Sanjeev Kumar (Policy No. 99087723)

          (iii)    Sharanpreet Kaur (Policy No. A3692683)

As the death of policyholder under the said 4 policies were found to have occurred less than 1 year of issuance of the policies, the company had initiated an internal investigation. The investigation revealed multiple points of suspicions which point out that Lakhwinder Singh and Sweety Arora are running nexus for committing insurance fraud. The details of the said policies are associated suspicions are listed below

(C)     The details of policies of Gurpreet Singh and associated suspicions areas follows:-

During the company’s investigation regarding the said policies of Gurpreet Singh the following suspicions were noted.

1. At the time of issuance of Policies of Gurpreet Singh, the salary slips of Gravity Printech India Private Limited submitted as income proof which show that Gurpreet Singh was working at that place. However, the said salary slips were found to be forged. The forgery was confirmed by the directors of Gravity Printech India Private Limited.
2. Moreover, when the photo captured at the medical checkup stage was shown to be the persons in the vicinity, checkup in place of actual Gurpreet Singh at the time of issuance of Gurpeet Singh’s Policies. The same was confirmed by the directors of Gravity Printech India Private Limited. The salary slips are forged and that an impersonator took the medical checkup in place of Gurpreet Singh.
3. Additional suspicions arose when Sweety Arora, while raising the death claim for policies of Gurpeet Singh, submitted salary slips showing that Gurpreet Singh was an employee of Pannu Mobile Zone Private Limited owned by Lakhwidner Singh.
4. Thus it is evident that the opposite party are jointly forging documents to get insurance policies issued and further raise fraudulent death claim.

(d)     The details of Policy of Sanjeev Kumar and associated suspicions are as follows:-

During the company’s investigation regarding the said policy of Sanjeev Kumar the following suspicions were noted.

1. At the time of issuance of policy of Sanjeev Kumar, the income of Sanjeev Kumar was declared as Rs. 10 Lakhs per annum. However, at the time of death claim, Sweety Arora submitted a salary slip of Sanjeev Kumar, which shows his income as Rs. 25,000/- per month.
2. The suspicion arose further when it was noted that the salary slip is of Pannu Mobile Zone Private Limited issued by Lakhwinder Singh. Thus further strengthens the suspicion that forged documents are being created and submitted by Sweety Arora with the help of Lakhwinder Singh to raise fruaudlent death claim.

(e)      Details of policy of Sharanpreet Kaur and associated suspicions are as follows:-

During the company’s investigation regarding the said policy of Sharanpreet Kaur, the following suspicions were noted:

1. For the policy of Sharanpreet Kaur, nominee is Lakhwinder Singh. he has shown that Sharanpreet Kaur died in Hospital in the death claim form on 13 October 2022. However, in reality, Sharanpreet was forcibly discharged from the hospital on 13 October 2022 against the express advise of the doctor. She died sometime later, away from the care of the hospital.
2. Moreover, as per the death claim raised by Lakhwinder Singh for policy of Sharanpreet, it is shown that the death caused was due to accident. The same is claimed basis the General Diary entry No. 020 made on 2 November 2022, at Police Station Sohana. As per the said GD entry submitted with the claim form, the car containing Sharanpreet Kaur which was being driven by Lakhwinder Singh collided with a stationary truck on 27 September 2022.
3. However, it is peculiar to note that the GD entry was made after more than 3 weeks from the death of Sharanpreet and moreover Lakhwinder Singh did not report the death of Sharanpreet to the Police while getting the GD entry made. Moreover, Lakhwinder Singh escaped the accident with no injuries whereas Sharanpreet Kaur is shown to be hospitalized twice, i.e.,from 27 September 2022 to 29 September 2022 and 6 October 2022 to 13 October 2022.
4. The timeline of events i.e., firstly Sharanpreet being forcibly discharged from the hospital on 13 October 2022 against the express advice of the doctor, secondly, GD entry being made without mentioning her death and thirdly, no post-mortem report being made regarding her death, together raise the suspicion that Sharanpreet has died in mysterious circumstances and clear foul play is involved in raising death claim under her policy.

While investigating further into the abovementioned suspicions and looking at the fraud in its entirety, the following points were noted:

1. The death of abovementioned policyholders has occurred within 1 year of policy issuance.
2. Lakhwinder Singh and Sweety Arora have been Nominees in all Policies at different points of time. For example, at the time of policy issuance for Gurpreet Singh, the nominee was Lakhwinder Singh however it was later changed to Sweety Arora on request of Gurpreet Singh.
3. That at the time of claim assessment, when Sweety Arora was requested to prove that she is the sister of Sanjeev Kumar and wife of Gurpreet Singh, till date she hasn't been able to prove the same to the Company with any documentary evidence.
4. All the deceased persons are shown to be working at one Company i.e. Pannu Mobile Zone Private Limited whose director is Lakhwinder Singh. Gurpreet Singh and Sanjeev Kumar are shown to be employees at Pannu Mobile Zone Private Limited and Sharanpreet Kaur was one of the directors of Pannu Mobile Zone Private Limited before her death.
5. The address of Sweety Arora and Lakhwinder Singh is identical as per their KYC
6. Even the email ID submitted under all the said policies at the time of issuance application is same. i.e..
7. Moreover, other persons, such as the impersonator who took the medical checkup in place of Gurpreet Singh, are working together with the abovementioned to defraud the Company

Hence, it is clear that these above named 2 people i.e. Lakhwinder Singh and Sweety Arora, are running a systematic and organized Insurance Scam / Fraud in the region, and are taking assistance of other individuals such as their family members other relatives, known associates, etc. to defraud the Company. COMPLAINT INVOLVES COMPLICATED QUESTIONS OF LAW AND FACTS: That the present case involves serious issues of Cheating and fraud. Such a case requires a proper trial by a civil / criminal court and is not possible in a summary trial or in an alternate dispute resolution. 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 by a civil or a criminal court. The facts of present case are highly complicated in view of the apparent fraud involved. From the above mentioned points it can be seen that an external fraud has been committed against the company by the complainant by availing an insurance policy. Therefore, present complaint can be only adjudicated before a Civil Court through proper trial and adducing substantive evidences Further for adjudication of present complaint following examinations are highly necessary

a        Examination of Complainant No 1.

b        Examination of Sweety Arora and others

c        Examination of neighbor's or people living in the vicinity      of the Complainant,

d        Examination of other family members as well relatives of DLA,

e        Examination of record or person deemed necessary during proceedings

Proceedings before this Commission are essentially summary in nature thus adjudication of issues which involve disputed factual questions requiring detailed trial by way of adducing evidence cannot be tried before this Commission. Thus, the present complaint ought not to be adjudicated before Commission through summary proceedings. IMPORTANCE OF A PROPOSAL FORM: The proposal form is not merely a document to be signed and submitted for formality. It is the basis of the contract of insurance between the Insurer and the Insured. It is the mode of providing information to the insurer, so as to enable them to exercise a lawful right to evaluate the life before providing its service by covering the Life. A reference is most respectfully made here to Regulation 4(8) of the IRDA (Protection of Policyholders' Interests) Regulations, 2017 which provides that "Proposal Form" means a form to be filled in by the proposer for insurance, for furnishing all material information required by the insurer in respect of a risk, in order to enable the insurer to decide whether to accept or decline, to undertake the risk, and in the event of acceptance of risk, to determine the rates, terms and conditions of a cover to be granted. Explanation: "Material" for the purpose of these regulations shall mean and include all important, essential and relevant information in the context of underwriting the risk to be covered by the insurer. Further, as per the provisions of Regulation 19 (2) and Regulation 19 (3) of the IRDA (Protection of Policyholders' Interests) Regulations, 2017, the contents of which have been reproduced herein below, the Life Assured was under a bounden obligation, to disclose all material information to the Company, at the time of proposal.

"19. (2) The requirements of disclosure of "material information regarding a proposal or policy apply, under these regulations, both to the insurer and the insured.

19 (3) The policyholder shall furnish all information that is sought from him by the insurer and also any other information which the insurer considers as having a bearing on the risk to enable the latter to assess properly the risk sought to be covered by a policy"

Furthermore, the subject policy was issued by giving false declaration. Since the subject matter viz. policy was obtained fraudulently dishonestly and by misrepresentation therefore, the same is null-and-void and no benefit is payable thereunder. THE RESPONDENTS WERE DECEIVED INTO UNDERTAKING RISK ON LIFE OF THE LIFE ASSURED. The insured is obliged to give full and correct information on all matters which would influence the judgment of a prudent insurer in determining whether he will accept the risk, and if he would, at what rate of premium and subject to what conditions. The material facts, as having a bearing on the risk in life insurance contracts, include the age, income, state of health or illness (present & past) occupation and habits, particulars of previous insurance etc, which are only within the knowledge of the Proposer / Life Assured. The insurer, therefore, has to rely entirely on the information, which the Proposer / Life Assured gives at the time of proposal. If a material fact is suppressed, the insurer will be misled about the risk covered, and hence the same will vitiate the contract. The insurer will then be well within its right to treat the contract as void as per the terms and conditions of the policy document. From the above it is clear that the Deceased Life Assured deliberately misled the Company to accept the proposal form by concealing material information and furnishing false replies regarding his income and occupation while filing up the proposal form which were very essential for underwriting the proposal for life insurance, the opposite party Company was deceived into providing risk cover to the Deceased Life Assured, and was denied a fair chance to assess the risk on her life Had the true and correct information were given to the opposite party Company at the time of the proposal stage then the policy would not have been issued at all and the proposal would have been rejected upfront by the opposite party Company as the alleged Life Assured was entitled to the subject product issued by the opposite party Company. Thus the present complaint is liable to be dismissed on this ground alone. INSURANCE IS A CONTRACT BINDING TWO PARTIES. 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 In the present case, the opposite parties have strictly acted as per the terms and conditions of the policy contract. That the Commission cannot pass any order in contravention to the terms and conditions of the policy contract. The "Incontestability" clause under the T & C clearly states that the Company may call the policy into question in- accordance with Section. 45 of the Insurance act, 1938 as amended from time to time. It is submitted that under terms and conditions categorically mentions that "Incontestability will be as per Section 45 of the Insurance Act, 1938 as amended from time to time". Furthermore, the terms and conditions headed as Non-Disclosure & Fraud also stipulate that "Non-Disclosure & Fraud will be as per as per Section 45 of the Insurance Act, 1938 as amended from time to time. The policy is subject to the terms and conditions as mentioned in the policy documents and is governed by the laws of India." In view of the above, the opposite party made it clear from the inception of the contract about the consequences for making any wrongful statements and in spite of such complete disclosures by the opposite party, the declaration and answers of the DLA at the time of proposal/ revival stage were found to be incorrect and hence the opposite party was well within their statutory right to declare the subject policies as null and void as is rightly done so in the present case.  COMPLAINANT HAS APPRAOCHED THE COMMISSION WITH UNCLEAN HANDS. the Complainant has not acted in good faith with respect to subject of this Complainant 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" In the present case, the Claimant is an accomplice to the elaborate fraud committed by the DLA. The Complainant is intentionally trying to mislead the commission by stating wrong facts and thus should be put to strict of this allegation. The Complainant has provided false stories to mislead the Commission. This clearly shows that the Complaint is deliberately and consciously withholding these important facts to mislead this Commission. Thus the Complaint deserves to be dismissed in the limine COMPLAINT IS DEVIOD OF ANY MATERIAL PARTICULARS: The complaint is devoid of any material particulars, and has been filed merely to harass and gain undue advantage and unjustified and illegal monies from the opposite party by fraudulent activities, and hence the Complaint deserves to be dismissed in limine.The Complaint has been filed with ulterior motive and malafide intention, to defraud and cause harassment and prejudice to the opposite party, which is a company of long standing and high repute, and to illegal extract money from it without any entitlement and just cause or valid reason. The subject matter for the above policy itself is proved to be initiated by fraudulent act, and the complainant is guilty of suggesto vari supresso falsi. Therefore the said policy is rightly declared void by the opposite party Company, and consequently, no benefit or amount under the said policy becomes payable. RESPONDENT HAS ACTED WITHIN THE LEGAL FRAMEWORK: As per the Indian Contract Act 1872 one of the essential elements for a valid contract is free consent. When consent to an agreement is caused by fraud of misrepresentation, the agreement is a contract voidable at the option of the party whose consent was so caused as the same is not a free consent. As per Section 17 of the Indian Contract Act, 1872, the term "Fraud" has been defined as "Fraud" means and includes any of the following acts committed by a party to a contract, or with his connivance, or by his agent, with intent to deceive another party thereto of his agent, or to induce him to enter into the contract –

a        the suggestion, as a fact, of that which is not true, by one who does not believe it to be true;

b.       the active concealment of a fact by one having knowledge or believe of the fact;

c.       a promise made without any intention of performing it

d.       any other act fitted to defective;

e.       any such act or omission as the law specifically declares to be fraudulent

Section 18 of the Indian Contract Act, 1872 defines “Misrepresentation” as

(ii)     The positive assertion, in a manner not warranted by the information of the person making it, of that which is not true, though he believes it to be true

3. Any breach, of duty which, without an intent to deceive, gains an advantage to the person committing it, or any one claiming under him, by misleading another to his prejudice or to the prejudice of any one claiming under him;
4. Causing, however, innocently, a party to an agreement to make a mistake as to the substance of the thing which is the subject of the agreement.

In the present case, it was discovered that the subject policy was issued fraudulently on the basis of active and deliberate concealment of material facts. Thus in view of the above established position of law and on finding concealment of facts in due knowledge of the DLA, the opposite party rightly rejected claim of complainant and declared subject policy null and void. The claim of the complainant/ claimant was rejected by the company and the opposite party was constrained to null and void the subject policy on the aforementioned grounds of misrepresentation. The decision was duly communicated to the complainant vide letter dated 21.7.2023. In accordance to Section 45 of the Insurance Act, 1938, the premium received i.e. Rs. 91,395 under the disputed policy was duly refunded to the complainant vide NEFT in the IDFC First Bank Account of the complainant. No act and conduct of opposite party has put the complainant under mental agony, tension, physical pain and pecuniary loss as alleged. The complainant has failed to make out any cause of deficiency of service against the opposite party as alleged or otherwise, within the meaning of Consumer Protection Act as there is no deficiency of service on the part of opposite party. The complainant has not established any deficiency in service on the part of the opposite parties while rendering services to the insured nor were the opposite parties indulged in to any unfair or unethical trade practice. On 2.9.2021, the opposite party was in receipt of duly filled proposal form bearing No. OS17638278 alongwith Customer Declaration Form, from Ms. Sharanjeet Kaur, through ICICI Bank Ltd. (Agent) requesting for the issuance of ICICI PRULIFE IPROTECT SMART Plan. Based on the information provided in the form and believing it to be true and correct, the opposite parties issued policy bearing No. A3692683 on 2.11.2021 to Ms. Sharanjit Kaur. At the time of obtaining the policy, the company had sought specific questions with respect to the income, occupation and education of the deceased life assured. The policy under question is outcome of the fraud which has been played on the opposite party company. The opposite party company was misled to issue the aforesaid policy on the life of the Life Assured. Thus, the DLA and the complainant have committed grave fraud against the opposite party company and is now trying to gain illegal advantages. The compliant is devoid of any material particulars, and has been filed merely to harass and gain undue advantage and unjustified monies from the opposite parties. The opposite parties have denied the other contents of the complaint and prayed for dismissal of the same. 

3        The complainant has filed rejoinder to the written version filed by the complainant by alleging that this Hon’ble Commission is having pecuniary as well as territorial jurisdiction to deal with the matter and decide the same.  Nothing was hidden or wrongly stated by the deceased insured at the time of taking policy in question. The claim of the policy in question of which complainants are beneficiaries, had been wrongly and illegally repudiated by opposite party. The policy in question was issued by opposite party only after verification and satisfaction of the income proof of the deceased insured. At this stage after the death of the life assured, raising such issue regarding income of the deceased insured cannot be tenable after about one year of issue of policy in question policy in question. Since investigator of the opposite party has stated in his report that the claim was genuine, the repudiation of the claim after that is nothing but gross deficiency in service on the part of opposite party, making complainants entitled for exemplary compensation. No evidence has been produced by opposite party about contentions of preliminary objection number three. Even the written version of opposite party, not supported by any affidavit or evidence is not tenable and cannot be read as such. Even the annexures mentioned in the written version have not been tendered with the written version. Nothing about income of the deceased insured was ever concealed from the opposite party. It is nowhere in any document that the deceased was working in mobile shop as because the investigator of opposite party has himself stated that the deceased was working as director and was running a business under the name and style of Pannu Mobile Zone Private Limited. At the time off issuing the policy, all requisite documents regarding proof of income of the insured including her income tax returns, financial records as well as her proof of being director of the company from which she was drawing remuneration/ salary were submitted with read opposite party. Further it was disclosed by the insured that the insured had business income as well, i.e. why in reply to para 1 wherein screenshot of the proposal form reproduced shows source of income of deceased insured as salary from Pvt.Ltd. Company as well as Business income which was verified by O.P.s at the time of issuing the policy in question. The opposite party in it's repudiation letter even disputed qualification of insured now deceased after her death just to repudiate the genuine claim with regard to her accidental death which the investigator of opposite party had otherwise recommended to be payable claim. For ready reference income tax return of the deceased insured for the year ending 31.03.2023 is Ex. C-23.  The opposite party has concealed the record about income of the deceased insured submitted by her at the time of getting the insurance policy in question which was verified by opposite party as well as their underwriters and after full satisfaction with this regard, the policy was issued. By leveling such bald and frivolous allegations of procuring insurance policy by misrepresentation or by fraud against the insured now deceased, opposite party has made itself liable for exemplary damages. By leveling serious false allegations against the deceased insured as well as complainants, O.P.s have made themselves liable for exemplary punitive damages in favour of the complainants. Even on this account, O.P.s filed police complaint against complainants leveling similar allegations. The Police authorities investigated the matter at length and concluded that no cognizable offence was made out and further no document/ information submitted by the insured or the complainants for the purpose of insurance policy or the claim was found to be false. Further, even the investigator of the opposite parties found the claim to be genuine. Furthermore, even during the police investigation against complaint of the O.Ps, police authorities reached the conclusion that the complainants have got no co-relation with  other claims alleged in this para, and that the documents of other polices referred in this para too are genuine and even the cause of death of the deceased insured too has been proved by Police Authorities in the complaint of the O.P.s as per Ex.C-16. Even the investigator of O.Ps reached the conclusion that the claim is genuine and payable, leaving no scope for repudiation of the genuine claim. Since the police authorities on the complaint of O.P.s have ruled out any element of forgery or fraud, rather proved the cause of death,  and the findings of police authorities have not been challenged by O.P.s any where, and further the investigator of O.P.s after thorough investigation gave detailed report and have itself recommended the claim against the policy in question to be genuine and payable, and further to that the policy was issued by O.P.s in the first instance after the O.P.s as well as their underwriters having thoroughly scrutinized the documents with regard to the credentials of the deceased insured including financial and other credentials of the deceased insured, thus now denying genuine claim on flimsy grounds beyond record and facts is not tenable, and the complainant is entitled for claim amount along with interest and compensation as well. There is no complicated or disputed fact which could oust jurisdiction of this Hon’ble Commission. Bald allegations of fabrication and fraud without any evidence, what to talk of cogent evidence cannot become reason for ousting the matter from the jurisdiction of this Commission. Since the police authorities on the complaint of O.P.s have ruled out any element of forgery or fraud, rather proved the cause of death, and further the investigator of O.P.s after thorough investigation gave detailed report and have itself recommended the claim against the policy in question to be genuine and payable, and further to that the policy was issued by O.P.s in the first instance after the O.P.s as well as their underwriters having thoroughly scrutinized the documents with regard to the credentials of the deceased insured including financial and other credentials of the deceased insured, thus now denying genuine claim on flimsy grounds beyond record and facts is not tenable, and the complainant is entitled for claim amount along with interest and compensation as well. Bald allegations of fabrication and fraud without any evidence, what to talk of cogent evidence cannot become reason for ousting the matter from the jurisdiction of this Commission. Since the police authorities on the complaint of O.Ps have ruled out any element of forgery or fraud, rather proved the cause of death, and further the investigator of O.Ps after thorough investigation gave detailed report and have itself recommended the claim against the policy in question to be genuine and payable, and further to that the policy was issued by O.P.s in the first instance after the O.P.s as well as their underwriters having thoroughly scrutinized the documents with regard to the credentials of the deceased insured including financial and other credentials of the deceased insured, thus now denying genuine claim on flimsy grounds beyond record and facts is not tenable, and the complainant is entitled for claim amount along with interest and compensation as well. The deceased insured did not give any false or fabricated document or false information to O.P.s for the purpose of issuing the policy in question making the claim liable to be non-payable. Rather it is the O.Ps who have committed gross deficiency in service about denying the genuine claim arbitrarily and illegally making them liable for punitive damages in addition to the claim amount with interest. The complainant about IRDA regulations are replied in this way, the deceased insured did not give any false or fabricated document or false information to O.Ps for the purpose of issuing the policy in question making the claim liable to be non-payable. Rather it is the O.P.s who have committed gross deficiency in service about denying the genuine claim arbitrarily and illegally making them liable for punitive damages in addition to the claim amount with interest. Since there was no element of false declaration, nor the policy was obtained fraudulently or dishonestly or by misrepresentation, rather correct information with regard to credentials was submitted by the deceased insured, and this stood vindicated as the police authorities on the complaint of O.P.s have ruled out any element of forgery or fraud, rather proved the cause of death, and further the investigator of O.P.s after thorough investigation gave detailed report and have itself recommended the claim against the policy in question to be genuine and payable, and further to that the policy was issued by O.P.s in the first instance after the O.P.s as well as their underwriters having thoroughly scrutinized the documents with regard to the credentials of the deceased insured including financial and other credentials of the deceased insured, thus now denying genuine claim on flimsy grounds beyond record and facts is not tenable, and the complainant is entitled for claim amount along with interest and compensation as well. Since no information called for was concealed by the deceased insured at the time of getting the policy in question, rather correct information with regard to credentials was submitted by the deceased insured, and this stood vindicated as the police authorities on the complaint of O.P.s have ruled out any element of forgery or fraud, rather proved the cause of death, and further the investigator of O.P.s after thorough investigation gave detailed report and have itself recommended the claim against the policy in question to be genuine and payable, and further to that the policy was issued by O.P.s in the first instance after the O.P.s as well as their underwriters having thoroughly scrutinized the documents with regard to the credentials of the deceased insured including financial and other credentials of the deceased insured, thus now denying genuine claim on flimsy grounds beyond record and facts is not tenable, and the complainant is entitled for claim amount along with interest and compensation as well.  Since no information called for was concealed by the deceased insured at the time of getting the policy in question, rather correct information with regard to credentials was submitted by the deceased insured, and this stood vindicated as the police authorities on the complaint of O.P.s have ruled out any element of forgery or fraud, rather proved the cause of death, and further the investigator of O.P.s after thorough investigation gave detailed report and have itself recommended the claim against the policy in question to be genuine and payable, and further to that the policy was issued by O.P.s in the first instance after the O.P.s as well as their underwriters having thoroughly scrutinized the documents with regard to the credentials of the deceased insured including financial and other credentials of the deceased insured, thus now denying genuine claim on flimsy grounds beyond record and facts is not tenable, and the complainant is entitled for claim amount along with interest and compensation as well. O.P.s have deliberately concealed the documents submitted to O.P.s at the time of issuing the policy in question, which are material piece of evidence. Bald allegations of fabrication and fraud without any evidence, what to talk of cogent evidence cannot become reason for ousting the matter from the jurisdiction of this Commission. Since correct information as called upon was given by the deceased insured at the time of issuing the same, and this stood vindicated as the police authorities on the complaint of O.P.s have ruled out any element of forgery or fraud, rather proved the cause of death, and further the investigator of O.P.s after thorough investigation gave detailed report and have itself recommended the claim against the policy in question to be genuine and payable, and further to that the policy was issued by O.P.s in the first instance after the O.P.s as well as their underwriters having thoroughly scrutinized the documents with regard to the credentials of the deceased insured including financial and other credentials of the deceased insured, thus now denying genuine claim on flimsy grounds beyond record and facts is not tenable, and the complainant is entitled for claim amount along with interest and compensation as well. Since there was no element of false declaration, nor the policy was obtained fraudulently or dishonestly or by misrepresentation, rather correct information with regard to credentials was submitted by the deceased insured, and this stood vindicated as the police authorities on the complaint of O.P.s have ruled out any element of forgery or fraud, rather proved the cause of death, and further the investigator of O.P.s after thorough investigation gave detailed report and have itself recommended the claim against the policy in question to be genuine and payable, and further to that the policy was issued by O.P.s in the first instance after the O.P.s as well as their underwriters having thoroughly scrutinized the documents with regard to the credentials of the deceased insured including financial and other credentials of the deceased insured, thus now denying genuine claim on flimsy grounds beyond record and facts is not tenable, and the complainant is entitled for claim amount along with interest and compensation as well. Since there was no element of false declaration, nor the policy was obtained fraudulently or dishonestly or by misrepresentation, rather correct information with regard to credentials was submitted by the deceased insured, and this stood vindicated as the police authorities on the complaint of O.P.s have ruled out any element of forgery or fraud, rather proved the cause of death, and further the investigator of O.P.s after thorough investigation gave detailed report and have itself recommended the claim against the policy in question to be genuine and payable, and further to that the policy was issued by O.P.s in the first instance after the O.P.s as well as their underwriters having thoroughly scrutinized the documents with regard to the credentials of the deceased insured including financial and other credentials of the deceased insured, thus now denying genuine claim on flimsy grounds beyond record and facts is not tenable, and the complainant is entitled for claim amount along with interest and compensation as well. Since there was no element of false declaration, nor the policy was obtained fraudulently or dishonestly or by misrepresentation, rather correct information with regard to credentials was submitted by the deceased insured, and this stood vindicated as the police authorities on the complaint of O.P.s have ruled out any element of forgery or fraud, rather proved the cause of death, and further the investigator of O.P.s after thorough investigation gave detailed report and have itself recommended the claim against the policy in question to be genuine and payable, and further to that the policy was issued by O.P.s in the first instance after the O.P.s as well as their underwriters having thoroughly scrutinized the documents with regard to the credentials of the deceased insured including financial and other credentials of the deceased insured, thus now denying genuine claim on flimsy grounds beyond record and facts is not tenable, and the complainant is entitled for claim amount along with interest and compensation as well. Since there was no element of false declaration, nor the policy was obtained fraudulently or dishonestly or by misrepresentation, rather correct information with regard to credentials was submitted by the deceased insured, and this stood vindicated as the police authorities on the complaint of O.P.s have ruled out any element of forgery or fraud, rather proved the cause of death, and further the investigator of O.P.s after thorough investigation gave detailed report and have itself recommended the claim against the policy in question to be genuine and payable, and further to that the policy was issued by O.P.s in the first instance after the O.P.s as well as their underwriters having thoroughly scrutinized the documents with regard to the credentials of the deceased insured including financial and other credentials of the deceased insured, thus now denying genuine claim on flimsy grounds beyond record and facts is not tenable, and the complainant is entitled for claim amount along with interest and compensation as well. Since there was no element of false declaration, nor the policy was obtained fraudulently or dishonestly or by misrepresentation, rather correct information with regard to credentials was submitted by the deceased insured, and this stood vindicated as the police authorities on the complaint of O.P.s have ruled out any element of forgery or fraud, rather proved the cause of death, and further the investigator of O.P.s after thorough investigation gave detailed report and have itself recommended the claim against the policy in question to be genuine and payable, and further to that the policy was issued by O.P.s in the first instance after the O.P.s as well as their underwriters having thoroughly scrutinized the documents with regard to the credentials of the deceased insured including financial and other credentials of the deceased insured, thus now denying genuine claim on flimsy grounds beyond record and facts is not tenable, and the complainant is entitled for claim amount along with interest and compensation as well. Since there was no element of false declaration, nor the policy was obtained fraudulently or dishonestly or by misrepresentation, rather correct information with regard to credentials was submitted by the deceased insured, and this stood vindicated as the police authorities on the complaint of O.P.s have ruled out any element of forgery or fraud, rather proved the cause of death, and further the investigator of O.P.s after thorough investigation gave detailed report and have itself recommended the claim against the policy in question to be genuine and payable, and further to that the policy was issued by O.P.s in the first instance after the O.P.s as well as their underwriters having thoroughly scrutinized the documents with regard to the credentials of the deceased insured including financial and other credentials of the deceased insured, thus now denying genuine claim on flimsy grounds beyond record and facts is not tenable, and the complainant is entitled for claim amount along with interest and compensation as well. Since there was no element of false declaration, nor the policy was obtained fraudulently or dishonestly or by misrepresentation, rather correct information with regard to credentials was submitted by the deceased insured, and this stood vindicated as the police authorities on the complaint of O.P.s have ruled out any element of forgery or fraud, rather proved the cause of death, and further the investigator of O.P.s after thorough investigation gave detailed report and have itself recommended the claim against the policy in question to be genuine and payable, and further to that the policy was issued by O.P.s in the first instance after the O.P.s as well as their underwriters having thoroughly scrutinized the documents with regard to the credentials of the deceased insured including financial and other credentials of the deceased insured, thus now denying genuine claim on flimsy grounds beyond record and facts is not tenable, and the complainant is entitled for claim amount along with interest and compensation as well. Since there was no element of false declaration, nor the policy was obtained fraudulently or dishonestly or by misrepresentation, rather correct information with regard to credentials was submitted by the deceased insured, and this stood vindicated as the police authorities on the complaint of O.P.s have ruled out any element of forgery or fraud, rather proved the cause of death, and further the investigator of O.P.s after thorough investigation gave detailed report and have itself recommended the claim against the policy in question to be genuine and payable, and further to that the policy was issued by O.P.s in the first instance after the O.P.s as well as their underwriters having thoroughly scrutinized the documents with regard to the credentials of the deceased insured including financial and other credentials of the deceased insured, thus now denying genuine claim on flimsy grounds beyond record and facts is not tenable, and the complainant is entitled for claim amount along with interest and compensation as well.  Since there was no element of false declaration, nor the policy was obtained fraudulently or dishonestly or by misrepresentation, rather correct information with regard to credentials was submitted by the deceased insured, and this stood vindicated as the police authorities on the complaint of O.P.s have ruled out any element of forgery or fraud, rather proved the cause of death, and further the investigator of O.P.s after thorough investigation gave detailed report and have itself recommended the claim against the policy in question to be genuine and payable, and further to that the policy was issued by O.P.s in the first instance after the O.P.s as well as their underwriters having thoroughly scrutinized the documents with regard to the credentials of the deceased insured including financial and other credentials of the deceased insured, thus now denying genuine claim on flimsy grounds beyond record and facts is not tenable, and the complainant is entitled for claim amount along with interest and compensation as well. The premium amount paid by the deceased insured had been credited in the account of complainant No.1 by O.P.s in an attempt to get rid of the liability of making payment of the genuine claim. Since there was no element of false declaration, nor the policy was obtained fraudulently or dishonestly or by misrepresentation, rather correct information with regard to credentials was submitted by the deceased insured, and this stood vindicated as the police authorities on the complaint of O.P.s have ruled out any element of forgery or fraud, rather proved the cause of death, and further the investigator of O.P.s after thorough investigation gave detailed report and have itself recommended the claim against the policy in question to be genuine and payable, and further to that the policy was issued by O.P.s in the first instance after the O.P.s as well as their underwriters having thoroughly scrutinized the documents with regard to the credentials of the deceased insured including financial and other credentials of the deceased insured, thus now denying genuine claim on flimsy grounds beyond record and facts is not tenable, and the complainant is entitled for claim amount along with interest and compensation as well. Bald allegations of fabrication and fraud without any evidence, what to talk of cogent evidence cannot become reason for ousting the matter from the jurisdiction of this Hon’ble Commission. Thus under these circumstances, the present complaint deserves to be allowed with reliefs claimed to be awarded in toto in addition to the exemplary damages for repeatedly making such  derogatory comments against the deceased insured which smack inhuman behavior of O.P.s towards their genuine customers as it shows the attitude of O.P.s just to grab upon the money of the insured and repudiate the genuine claims on arbitrary grounds leveling bald and derogatory allegations. Since there was no element of false declaration, nor the policy was obtained fraudulently or dishonestly or by misrepresentation, rather correct information with regard to credentials was submitted by the deceased insured, and this stood vindicated as the police authorities on the complaint of O.P.s have ruled out any element of forgery or fraud, rather proved the cause of death, and further the investigator of O.P.s after thorough investigation gave detailed report and have itself recommended the claim against the policy in question to be genuine and payable, and further to that the policy was issued by O.P.s in the first instance after the O.P.s as well as their underwriters having thoroughly scrutinized the documents with regard to the credentials of the deceased insured including financial and other credentials of the deceased insured, thus now denying genuine claim on flimsy grounds beyond record and facts is not tenable, and the complainant is entitled for claim amount along with interest and compensation as well. Bald allegations of fabrication and fraud without any evidence, what to talk of cogent evidence cannot become reason for ousting the matter from the jurisdiction of this Hon’ble Commission. Thus under these circumstances, the present complaint deserves to be allowed with reliefs claimed to be awarded in toto in addition to the exemplary damages for repeatedly making such derogatory comments against the deceased insured which smack inhuman behavior of O.Ps towards their genuine customers as it shows the attitude of O.Ps just to grab upon the money of the insured and repudiate the genuine claims on arbitrary grounds leveling bald and derogatory allegations committing gross deficiency in service as well as unfair trade practice. The complainant has denied the other contents of the written version and reiterated the stand as taken in the complaint.

4        We have heard the Ld. counsel for the complainant and opposite parties and have carefully gone through the record placed on the file and written arguments submitted by the complainant.

5        From the combined and harmonious reading of documents and pleadings is going to prove on record that the wife of complainant No. 1 and mother of complainant No. 2 Mrs. Sharanpreet Kaur were insured with O.Ps. under the Policy Plan ICICI Pru iProtect Smart vide Policy No. A3692683 for sum assured Rs. 1,00,00,000/-plus accidental death benefit of Rs. 10,00,000/- from 2.11.2021 against payment of yearly premium of Rs. 77,453/-.  The said policy was issued by O.Ps. after taking complete note of health status of the insured as well as after taking in to consideration the documentary evidence of the insured with regard to her address, financial status, income as well as income tax returns and other documents of M/S.PANNU MOBILE ZONE PVT.LTD. company where she was director & 50% shareholder as well as was having her ownership/ 50% partnership in PANNU MOBILE ZONE partnership firm. The life assured died on 13.10.2022 due to accidental injuries, copy of death certificate is Ex.C-2. Complainants are the only class one legal heirs of the deceased insured.  Late Mrs.Sharanpreet Kaur met with a road accident with a truck on 26.09.2022 near Kharar, Distt. Mohali in the late evening while being passenger in the car being driven by complainant No.1. The said incidence was immediately informed to the Police at their helpline No. 112. The said Printout of SMS received from the police with ref. No.1049308 on 26.09.2022 at 11.01.PM is Ex.C-3.  She was taken to Shalby Multispecialty Hospital, Mohali in unconscious condition with bleeding from nose, ear and bleeding per vaginum. The hospital authorities also sent message to area police station reporting admission of the patient with accidental injuries. Copy of MLC Information Form sent by the Hospital to Police Authorities is Ex.C-4. Complainant No.1 also suffered from minor injuries in the accident for which he got first aid from this hospital as well. Since the vehicle of complainant which met with an accident was insured with ICICI Lombard General Insurance vide Insurance Policy, a sister concern of O.Ps, and also the family of complainant was having Mediclaim Insurance Policy No.40151/IDOPD/212242000/01/000 during relevant times, ICICI Lombard General Insurance gave authorization for cashless treatment of the patient insured on 27.09.2022 itself, copy of which is Ex.C-5. she was discharged from the hospital on 29.09.2022 on DOMICILLIARY TREATMENT. Copy of discharge summary dated 29.09.2022 is Ex.C-6. On 6.10.2022, i.e. after one week, she was re-admitted in the same hospital with complaint at that time of DIZZINESS, CONVULSIONS, UNCONCIOUSNESS LASTING 3-4 MINUTES ABOUT ½ HR. BACK, SWEATING, COLD EXTREMITIES ½ HR BACK, BLEEDING PV FOR THE LAST 2-3 DAYS, HISTORY OF SAME EPISODES TWICE 2 DAYS BACK. During the course of treatment, patient/ insured in the hospital, she had cardiac arrest on 7.10.2022. MRI was done on 10.10.2022 showed acute hypoxic brain injury which resulted into POOR PROGNOSIS. Weaning off trial of ventilator and other life support systems failed indicating brain death. As the medical condition of the patient was not going to survive as told by the treating doctors, LAMA discharge was taken from the hospital, copy of LAMA Summary is Ex.C-7. Mrs.Sharanpreet Kaur died the same day within small time after LAMA discharge from the hospital after her ventilator was removed. Thereafter, the complainant No. 1 approached the police authorities to find out status of police report of the accident. The Police authorities filed General Diary dated 02.11.2022 for the incidence, copy of which is Ex.C-9. Thereafter the complainant No.1 lodged the claim with the opposite parties with all the requisite documents and the opposite parties assigned claim ID UDI199217. Meanwhile the claim of the vehicle of the complainant which was also damaged badly and was assigned claim No. MOT12884073 by ICICI Lombard General Insurance Company which was settled for Rs 1,86,781/- and same was received by the complainant. Since the opposite parties were not settling the genuine claim of the complainants, they were approached repeatedly, vide letter dated 24.11.2022 (Copy is Ex.C-13), 26.04.2023 (Copy is Ex.C-14) as well as 30.05.2023, (copy of which is Ex.C-15) and all the time it was informed that the claim is currently under process. However, to the dismay and shock of the complainant No.1, O.Ps. filed a complaint with Chandigarh Police dated 27.06.2023 against complainant No.1 for Forgery/ Cheating and Fraud with regard to the Policy and Claim thereon in question, clinching it with some other claims which had been repudiated by O.Ps. in the past. The Police thoroughly investigated the complaint and vide order/ report dated 7.08.2023 gave finding: “Matter is found to be related to non-sanctioning of insurance claim by insurance com complainant company. No cognizable offence has been found made out. Hence, the attached complaint may please be filed.” In that very report, the Police Authorities held that in the claims with which name of complainant No.1 had been arbitrarily associated by O.P.s, in those claims’ documents produced could not be proved to be forged documents as well. Police Report dated 7.08.2023 which includes complaint of O.Ps. against complainant No.1 is Ex.C-16. This report of Police also contained CLAIM INSVESTIGATION REPORT submitted by O.Ps with Police for the purpose of investigation which itself states at POINT/CLAUSE “G” of the report “This claim appears to be Genuine. LA passed away in a Road Accident, General Diary, Accident Spot Video, LA Summary, Discharge Summary and Treatment papers procured and enclosed herewith. No past medical history of LA found in this case.” Copy of the CLAIM INVESTIGATION REPORT is Ex.C-17. In the meantime, without waiting for the result of the Police Complaint made by O.Ps, and even ignoring their own Claim Investigation Report, vide letter dated 21.07.2023, the O.Ps repudiated the genuine claim of the complainants. In the meantime, the O.Ps credited the premium amount of the policy with interest Rs 91,395/- in the account of the complainant No.1. After receipt of arbitrary repudiation letter, complainant No.1 filed complaint/ review with Grievance Redressal Committee of O.Ps against illegal repudiation on 27.07.2023, copy of which is Ex.C-21. Till date no reply/ response has been received by complainants from their Grievance Redressal Committee though it is more than 5 months now when the same was filed. Further in the meantime, vide letter dated 12.09.2023, Copy of which is Ex.C-22, ICICI Lombard General Insurance Company made payment of the Personal Accident Claim of Rs 15,00,000/- (Rs.Fifteen Lac) under Policy No.3001/253494422/00/000  as Claim No.MOT138288234 with regard to the death of the deceased Mrs.Sharanpreet Kaur.  Feeling aggrieved by arbitrary act of the opposite parties, the complainant has filed the present complaint for the insurance claim of the policy

6        On the other hands, the case of the opposite parties have filed a detailed and lengthy written version by taking objections of maintainability, jurisdiction of this commission, Violation of Principle of utmost good faith. An insurance policy works on the principle of uberrima fides which means utmost good faith. Under an insurance policy, the proposer/ policy holder is bound to give true and correct information in proposal form without withholding any material information from the insurance company.  The opposite parties received claimant statement form (death claim) from the complainant stating that the L.A died on 13.10.2022 (within one year from the date of insurance policy). Since the death was within 3 years from the issuance of the policy, the same fell under the category of early claim.  Thus to verify the genuineness and veracity of the disputed claim as per Section 45 of the Insurance Act, 1938, the opposite party conducted an investigation. During the investigation, it was found that the LA had misrepresented her occupation and income. At the time of issuance, in the proposal form the LA had stated that she was a “Salaried Employee and Graduate” with annual income of Rs. 7,00,000/- however, during investigation it was revealed that the actual income of the LA was Rs. 3,00,000/- only and she was actually working in mobile shop. Thus it was clear that the complainant had attempted to defraud the opposite party, thus making the subject policy null and void. Hence, the opposite party rightly declared the subject policy null and void vide letter dated 21.7.2023 and the same was done in due compliance of provision of Section 45 of Insurance Act As such the present case is a perfect example of a very well-planned fraud against the opposite party company and the entire insurance industry. Thus the LA and the complainant have committed grave fraud against the opposite party company and is now trying to gain illegal advantages. Further during the investigation in the present case, the suspicious points were pointed out as detailed in written version. During the company’s investigation regarding the said policy of Sharanpreet Kaur, the following suspicions were noted:

(i)      For the policy of Sharanpreet Kaur, nominee is Lakhwinder Singh. he has shown that Sharanpreet Kaur died in Hospital in the death claim form on 13 October 2022. However, in reality, Sharanpreet was forcibly discharged from the hospital on 13 October 2022 against the express advise of the doctor. She died sometime later, away from the care of the hospital.

(ii)     Moreover, as per the death claim raised by Lakhwinder Singh for policy of Sharanpreet, it is shown that the death caused was due to accident. The same is claimed basis the General Diary entry No. 020 made on 2 November 2022, at Police Station Sohana. As per the said GD entry submitted with the claim form, the car containing Sharanpreet Kaur which was being driven by Lakhwinder Singh collided with a stationary truck on 27 September 2022.

(iii)    However, it is peculiar to note that the GD entry was made after more than 3 weeks from the death of Sharanpreet and moreover Lakhwinder Singh did not report the death of Sharanpreet to the Police while getting the GD entry made. Moreover, Lakhwinder Singh escaped the accident with no injuries whereas Sharanpreet Kaur is shown to be hospitalized twice, i.e.,from 27 September 2022 to 29 September 2022 and 6 October 2022 to 13 October 2022.

(iv)    The timeline of events i.e., firstly Sharanpreet being forcibly discharged from the hospital on 13 October 2022 against the express advice of the doctor, secondly, GD entry being made without mentioning her death and thirdly, no post-mortem report being made regarding her death, together raise the suspicion that Sharanpreet has died in mysterious circumstances and clear foul play is involved in raising death claim under her policy.

Hence, it is clearly evident that Lakhwinder Singh and Sweety Arora are responsible for forging documents to raise fraudulent death claims and are engaged in suspicious nexus-based activities to purchase policies on the life of persons who are either close to dying already or ultimately end up dying in mysterious circumstances.  Further the opposite parties stated in their written version that complaint involves complicated question of law and facts, As such, it requires a proper trial via civil/ criminal court and is not possible in a summary trial.

7        We have gone through the rival contentions of respected parties.

8        The opposite party has repudiated the claim of the complainants vide repudiation letter Ex. C-19 by alleging that as we have examined the claim on the basis of the documents leading to insurance of the above-mentioned policy, the documents submitted by you at the claim stage and the documents obtained by us during the course of the investigation carried out by us of the claim stage. After a detailed examination of the fact, circumstances of the case and on the basis of the aforesaid documents we have decided to decline the claim on the following grounds:-

a) General Diary has been registered by the Police on November 02, 2022 which only mentions about the road accident of the life assured which took place on Sep.27, 2022.

b) Even though the General Diary was lodged after 20 days of the death of the Life Assured there is no mention of the death in this record.

c) First information report is to be lodged immediately on the occurrence of the accident. However, in the present case, it was lodged by you on March 28,2023 i.e. 6 months after the occurrence of the accident and 5 months after death of the Life Assured.

d) Further no reason or confirmation has been provided by you regarding the delay in registering the FIR though specific provision for the same has been sought in the FIR.

e) It is also submitted that, neither you have submitted a Medico-legal cause of death certificate, nor you have submitted any certificate from the doctor who has declared the life assured dead despite the same being specifically sought by the company.

9        In the present case insurance is not disputed and it is also not disputed that DLA is died in the accident death certificate is Ex. C-2. Moreover, the complainant has placed on record insurance policy Ex. C-1 which shows that the policy started on 2.11.2021 and policy term is 47 years and same is valid up to 2 November 2068. As per policy sum assured is Rs. 1,00,00,000/- (One Crore) plus accidental death benefit of Rs. 10,00,000/- (Ten Lacs). The DLA died on 13.10.2022 i.e. during the currency period of the policy in question. It is pertinent to mention here that payment of Rs. 15,00,000/- has been made to the complainants by considering accident death by another insurance company i.e. sister concern vide letter dated 12.9.2023 Ex. C-22. As such, from the above said discussion it is clear that the DLA was insured with the opposite party and he died due to accident.

10      As per investigator report Ex. C-17 it supports the version of the complainant that the investigator himself observed that this claim appears to be genuine. LA passed away in a road accident, General Diary, Accident Spot Video, LA Summary, Discharge Summary and Treatment papers procured and enclosed herewith. No past medical history of LA found in this case. The opposite parties lodged a complaint with the police authority Chandigarh regarding FIR/ complaint against nexus-based insurance fraud and the said complaint was investigated thoroughly and it was held by the police as Matter is found to be related to non-sanctioning of insurance claim by insurance company. No cognizable offence has been found made out. Hence, the attached complaint may please be filed. In that very report, the police authorities held that in the claims with which name of complainant No. 1 had been arbitrarily associated by O.Ps in those claims, documents produced could not be proved to be forged documents as well. Police report dated 7.8.2023 which includes complaint of O.Ps against complainant No. 1 is Ex.C-16. It proves that the genuine claim of the complainant was wrongly repudiated. The opposite party has taken objection that this commission has no pecuniary jurisdiction to try and entertain the present complaint but as per new Consumer Protection Act 2019 this commission can try and entertain the present complaint as the premium amount paid of the policy in question (i.e. Rs 77,453/-) is well within pecuniary jurisdiction of this Commission. Moreover, this Commission has got the territorial jurisdiction also to try and entertain the present complaint because the complainants are permanent residents of village Mugal Chakk Pannuan P.O. & Tehsil Tarn Taran and policy document also bearing the address of DLA as village Mugal Chakk Pannuan P.O and Tehsil Tarn Taran District Tarn Taran.

11      The opposite party has also taken the objection that the complainant has violated the principle of utmost good faith. But the complainant has proved his case up to the mark which is closely associated with the report of surveyor as well as police authorities that the claim is genuine one.

12      As per repudiation letter the opposite party has raised the question that general diary has been registered by the police on  November 02, 2022 which only mentions about the road accident of the life assured which took place on Sep.27,2022. But as per Ex. C-3, it clearly proves that Complainant Lakhwinder Singh  has immediately reported the incident to the police on Number 112. Further the hospital authorities also intimated to the police authorities separately as such the same night, the opposite party cannot take the objection mentioned in their repudiation letter.

13      However, as per the repudiation letter the opposite party mentioned that during the claims evaluation it was noted that life assured had misrepresented and overstated her income. Further it was also noted that life assured was not salaried and was infact carrying a self employed business. But we are not agreed with the opposite parties that it is very much clear from the policy documents and it was disclosed by the insured to O.Ps. that the insured had business income as well and also shown the source of income of deceased insured as salary from private Ltd. company as well as business income which was verified by O.P at the time of issuance of policy in question.  Now the opposite party cannot raise the objection about the occupation and income of the DLA. In the present case, the opposite party has issued the policy in question after verifying all the facts related to the DLA and at this belated stage, opposite party cannot raise frivolous allegations of procuring insurance policy by misrepresentation or by fraud when claim has arisen under the policy. As per the repudiation letter, the opposite party has declined the genuine claim on very flimsy ground by ignoring the findings of genuineness of the claim which were given by their own investigator. Moreover, attention of this Commission was also drawn by the counsel for the complainants to the policy document (Exh.C-1) wherein it is mentioned that the policy was obtained by the complainant from ICICI Bank Ltd., and name of agent selling the policy being ICICI Bank Ltd. Thus for that reason, the bank as well as O.P.s had complete access to the bank accounts of the insured, and only after verifying financial/ income status of the deceased insured the policy was issued.

14      In the police investigation the claim of the complainant was found genuine. The police authority has investigated the complaint in detail and found that the complaint of the opposite party is baseless, as such, the police investigation report is admissible under the Indian Evidence Act.  The said report of the police authority found no elements of false declaration, fraud, dishonesty, misrepresentation and regarding the credential information.

15      Further the investigator of opposite party after thorough investigation gave detailed report and have itself recommended the claim against the policy in question to be genuine and payable, and further to that the policy was issued by O.P is in the first instance after the O.P as well as its underwriters having thoroughly scrutinized the documents with regard to credentials of deceased insured including financial and other credentials of deceased insured. 

16      Even otherwise, the opposite party has failed to file any document which are mentioned in their written version as Exhibit/ Annexure as well as the affidavit as evidence with written version as such, the written version cannot be considered on the above mentioned grounds and it is deemed that opposite party has nothing to rebut to the contentions in the complaint and can be taken as if no written version has been filed, which clearly proves that the opposite party has repudiated the genuine claim of the complainant arbitrarily.  It is a settled principal of law that the pleadings without any cogent evidence are of no use, and under these circumstances, even otherwise since no cognizance can be taken of such like  defective pleadings filed by Opposite Party in the name of their written version, the contentions of complainants are to be considered unrebutted  as such, and the complaint has to be allowed.

17      The opposite party has wrongly returned Rs. 91,395/- as premium amount plus interest just to escape from their liability of full insurance amount. As such the complainant is entitled to Rs. 1,00,00,000 (One Crore) for death claim and Rs. 10,00,000/- (Ten Lacs) for accidental benefit claim. By withholding the genuine claim of the complainants, the opposite party has committed deficiency in service as well as unfair trade practice.

18      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 seems 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.

Moreover, the opposite party has merely filed written version which are only allegations/ pleadings (which too are defective) and the same are to be proved by evidence and documents but the opposite party has not filed any affidavit and documents to prove their version, as such the written version filed by the opposite party cannot be read in the present case.

19      For the foregoing reasons we allowed the present complaint with costs against the opposite party.  The opposite party is directed to pay Rs. 1,09,08,605/- (Rs. One Crore, Nine Lacs, Eight thousand and six hundred five only)  (Rs.1,10,00,000- Rs.91,395) to the complainants.  The complainants have been harassed by the opposite party unnecessarily for a long time and complainant No.1 had to even undergo scrutiny/ face investigation  by the UT police on the complaint against him by Opposite Party with the allegation of precuring insurance policy of the deceased insured by fraud which was the policy authorities after detailed investigation declared to be false and consigned the same. By such arbitrary acts of Opposite Party and by repudiating this genuine claim under the policy, the rights of complainant No.2, who is minor have been compromised. Accordingly, we deem it fit that the complainants are also entitled to Rs.2,00,000/- as compensation on account of harassment and mental agony and Rs 50,000/- 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 complainants are entitled to interest @ 9% per annum, on the total awarded amount, from the date of order till its realization.  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