BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMRITSAR.

Consumer Complaint No.  242 of  2024

Date of Institution: 29.4.2024

                                                          Date of Decision:16.10.2024   

1. Rajinder Kaur , aged about 39 years wife of Late Sh. Pargat Singh
2. Karan Partap Singh aged about 11 years son of Late Sh. Pargat Singh
3. Agamjot Singh aged about 7 years son of Late Sh. Pargat Singh, both minor sons through their mother/natural guardian Smt.Rajinder Kaur i.e. complainant No.1 who has got no adverse interest against the minor children
4. Balwinder Kaur aged about 65 yers wife of late Sh. Mukhwinder Singh, all residents of Village Khanfatta, Distt. Gurdaspur 8872003024

Complainants

Versus

1. Manipal Cigna Health Insurance Company Limited (Formerly known as Cigna TTK Health Insurance Company Limited ) Having its Registered office at 401/402, 4^th Floor, Raheja , Titanium, Western Express Highway, Guregaon (East) Mumbai-400063 through its Managing Director/Director/Manager/Authorized Signatory/Person over all Incharge
2. Manipal Cigna Health Insurance Company Limited having its branch office at SCO 106, 6^th Floor, Ranjit Avenue, Distt. Shopping Centre, Amritsar through its Branch Manager/Authorized Signatory/Person over All Incharge

Opposite Parties

Complaint under section 34 & 35 of the Consumer Protection Act, 2019

Result : Complaint  Allowed

Counsel for the parties  :

For the  Complainants                        : Sh.Munish Kohli, Advocate      

For the Opposite Parties No.1 & 2     : Sh. R.P. Singh,Advocate

CORAM

Mr.Jagdishwar Kumar Chopra, President

Ms. Mandeep Kaur, Member

ORDER:-

Mr.Jagdishwar Kumar Chopra, President :-  Order of this commission will dispose of the present complaint filed by the complainant u/s   34 & 35  of the Consumer Protection Act, 2019.

Brief facts and pleadings

1.       Brief facts of the case of the complaint are that husband of  complainant No.1 , father of complainants No.2 & 3 and son of complainant No.4 namely Sh. Pargat Singh was insured with the opposite parties under the policy plan SARAL SURAKSHA BIMA POLICY vide policy No. SARSUR050022768 for the sum assured of Rs. 60,00,000/- (Rs. Sixty Lacs only) alongwith extra rider (Education grant) providing optional cover of education grant of 10% of base sum insured for per dependent child shall be payable on the admissible claim due to death or permanent total disability of the insured person  against the payment of yearly collective premium of Rs. 5411.71 covering risk for the period from 10.8.2022 to  9.8.2023, copy of policy schedule is Ex.C-1.  Only Insu. policy schedule was supplied  to the policy holder but the opposite parties neither explained/conveyed nor supplied any terms and conditions of the policy to the DLA. The abovesaid policy was issued by the opposite parties after taking complete note of health status of the insured as well as after taking into consideration all the documentary evidence of the insured  with regard to his address, financial status, income as well as income tax returns and other documents  of M/s. Goraya Brothers where he was partner to the extent of 30% share of the business, copy of partnership deed dated 26.6.2020 is Ex.C-2. Since the life assured died on2.4.2023 due to accidental injuries copy of death certificate is Ex.C-3. Complainant No.1 being nominee in the said policy and her class one legal heirs alongwith   complainants No.2 & 3 being minor sons  alongwith complainant No.4  are only class one legal heirs of deceased insured. Deceased Sh. Pargat Singh husband of complainant No.1, father of complainants No.2 & 3 and son of complainant No.4 unfortunately met with a roadside accident on 2.4.2023. It is pointed out that on the said unlucky day i.e. 2.4.2023 at about 2.40 p.m., DLA Pargat Singh was coming back from his sister’s house on his swift car bearing registration No. PB-06-BA-8158 alongwith his cousin Mandeep Singh and when they reached village Khushipur, all of sudden due to accidental slip the abovesaid car struck/hit with the roadside tree (Safaida Tree) and result of which DLA Pargat Singh received serious , multiple and grievous injuries on vital parts of his body and more particularly on his head/brain and Mandeep Singh also got fractures on his leg and due to wuch serious injuries DLA Pargat Singh died on the spot. Matter was reported to the policy of P.S. Kalanaur, Distt.Gurdaspur vide GD No. 037 dated 2.4.2023 on the statement of Avtar Singh son of Sh. Dhanna Singh and postmortem of DLA Pargat Singh  also got conducted at Civil Hospital, Gurdaspur, copy of GD  No. 037 is Ex.C-4, cop of OPD slip is Ex.C-5, copy of  post mortem report is Ex.C-6, copy of legal and valid driving license is Ex.C-7. Timely intimation  was also given to the opposite parties who deputed number of investigators against the provisions of IRDAI. Due to death of her husband in a very young age, the complainant No.1 was under great stress and depression and even inspite of that she had fully cooperated with the investigator deputed by the opposite parties  and she had recorded her statement  and provided all the relevant documents to the investigator from time to time as per their demand and investigator also took some signatures on blank papers on the pretext  of settling the claim   which the opposite parties are not settling the same.  Opposite parties vide letter dated 31.3.2024  repudiated the  claim of the complainants on the ground that “during investigation the opposite party noted multiple discrepancies and as such the claim stands repudiated under clause No. F.II.15, copy of repudiation letter is Ex.C-8. In between the claim of the vehicle  i.e. Swift car bearing registration No PB-06-BA-8158 which was also extensively damaged  badly in an accident was insured with the concerned insurer and the said Insu. company has processed the claim being total loss  basis and credited the claim amount in the bank account, copy of bank account statement is Ex.C-21. Similarly DLA Pargat Singh was also having one LIC Insu. policy and LIC has also processed  the claim amount in the bank account of complainant No.1 on 10.5.2023  and cop of LIC policy is Ex.C-22 and statement of account of complainant No.1 is Ex.C-23. One accident claim was paid by LIC under PMSBY scheme copy of which is Ex.C-24. After receipt of repudiation letter complainant No.1 filed review with Grievance Redressal Committee   but till date no reply has been received. Opposite parties No.1 & 2 have neither provided the investigation report nor has given any explanation of discrepancies points out by the subsequent investigator . It is pertinent to mention over here that as per the Insu. Regulatory and Development  Authority of India Regulations, 2017 “The surveyor shall subject to sub regulation 4 above, submit his final report to the insurer within 30 days of his appointment . A copy of surveyor’s report  shall be furnished by the insurer to the insured, if he so desires. However, such claims shall be settled by the insurer within  30 days of  receipt of final survey report and /or last relevant and necessary document as the case may be. However in the present case neither the surveyor has supplied copy of survey report  to the complainants nor the opposite party has processed the claim of the complainants till date .The aforesaid act of the opposite parties in repudiating  the  genuine claim of  complainants  is an act of deficiency in service, malpractice, unfair trade practice and has caused lot of mental agony, harassment, inconvenience besides financial loss to the complainant Vide instant complaint, complainants have sought for the following reliefs:-

(a)      Opposite parties be directed to pay the claim amount of Rs. 60,00,000/- for the death claim alongwith interest  @ 18% p.a. from the date of death i.e. 2.4.2023 till payment ;

(b)     Opposite parties be also directed to pay Rs. 12,00,000/- i.e. Rs. 6 lacs to each of complainants No.2 & 3 towards education grant as mentioned in policy schedule;

(c)      Compensation to the tune of Rs. 10,00,000/- may also be awarded to the complainants .

(d )    Opposite parties be also directed to pay Rs.50000/- as  litigation expenses to the complainants.

(e)      Any other relief to which the complainants are entitled be also awarded to the complainants.

Hence, this complaint.

2.       Upon notice   opposite parties appeared and filed written version taking certain preliminary objections therein interalia that deceased insured Mr. Pargat Singh applied two different proposals for availing two benefit policies from the opposite parties through his intermediary Ms. Sadhika Mahajan on 10.8.2022 to the tune of Rs. 80 lacs which raises suspicion as a normal prudent man with a gainful annual income of only Rs. 6 lacs would not generally avail coverage for such a huge amount ;  opposite parties on the basis of information submitted in the proposal form issued one policy to the complainant under the Plan namely “SARAL SURAKSHA BIMA”  bearing policy No. SARSUR050022768 for the period from 10.8.2022 to 9.8.2023 for the sum assured of Rs. 60 lacs providing accidental death coverage on the insured alongwith Education Grant Benefit of 10% of SI per dependent child. Another benefit policy was purchased by the complainant under the plan namely “Lifestyle Protection –Accident Care Basic” bearing policy No. LTPNAC050022333 for the period from 10.8.2022 to 9.8.2023 for the sum assured of Rs. 20 lacs  providing accidental death coverage to the insured ; that  this Hon’ble Commission has no pecuniary jurisdiction to try, entertain and decide the present complaint as the total claimed amount of Rs. 82,50,000/- which exceeds Rs. 50 lacs  , therefore, present complaint is liable to be dismissed on this short ground ; that complicated question of law & facts are involved in the present complaint which requires examination and cross examination of witness and voluminous evidence  which is not possible in summary proceedings under the  CPAct 2019; that  it is a clear case of fraud/misrepresentation, therefore, the present complaint is liable to be dismissed ; that the complainants have not come to the Hon’ble Commission with clean hands . It is submitted that opposite parties received two claims (SARSUR34) & (SARSUR35) under Policy No. SARSUR050022768 of Mr. Pargat Singh and another claim beraing No. LTPRAC476 was filed under policy No. LTPNAC050022333. As per complaint, it has been alleged that on 2.4.2023  the insured was going in his relative’s car bearing No. PB-02-BA-8158  with his brother Mandeep Singh and met with an accident and died on the spot. The complainants are now claiming accidental death benefit, however, opposite parties during investigation noted multiple discrepancies, therefore, being unable to admit the claim thereby repudiated the same as per terms and conditions of the policy clause No. F.1.7 which is reproduced hereinunder:-

F.1.7 Fraud

If any claim made by the insured person, is in any respect fraudulent or if any false statement or declaration is made or used in support thereof, or if any fraudulent means or devices are used by the insured person or anyone acting on his/her behalf to obtain any benefit under this policy, all benefits under this policy shall be forfeited.

During the course of investigation, multiple discrepancies have been noted with respect to the contradictory narration of accident in statements and police records, thus creating a reasonable doubt and suspicion as to the genuineness of the alleged accident and claims filed under both benefit policies.  Such discrepancies have been pointed out in the table below:-

It is submitted that as per narration of the complainant in her complaint, it has been stated that due to accidental slip, the car was struck /hit with the roadside tree, which is again in contradiction to her statements procured during the investigation. In view of the abovesaid discrepancies both the claims No. SARSUR34 (accidental death) and SARSUR35 (Education Grant) filed under policy No. SARSUR050022768 and claim No. LTPRAC476 (accidental death) filed under policy NO. LTPNAC050022333 were denied on the ground  of multiple discrepancies vide letter dated 31.3.2024 .Both the parties are bound with the terms and conditions of the policy  and in this case complainants have not complied with the terms and conditions of the policy which were duly supplied to the insured at the time of issuance of policy. In this regard the opposite parties have  placed reliance upon  Gas Ghar Vs. Oriental Insu.Co. Ltd. (2006) 3 CPJ 377, Aman Kapoor Vs. National Insu. Co.Ltd.  2017(3) CPJ page 319 wherein it has been held that ignorance of terms and conditions of policy is no excuse and providers no shelter to the petitioner complainant, Oriental Insu.Co.Ltd. Vs. Sony Cheriyan AIR 1999(SC) 3252, Polymat India P.Ltd. Vs. National Insu.Co.Ltd. AIR 2005 SC 286, M/s. Sumitomo Heavy Industries Ltd. V . Oil & Natural Gas Company AIR 2010 SC 3400 and Rashtriya Ispat Nigam Ltd. V. M/s. Dewan Chand Ram Saran AIR 2012 SC 2829.  It is further submitted that onus of proof of deficiency in service is on the complainant  and the opposite party No.1 relied upon the law laid down in SGS India Vs. Dolphin International Ltd. LL 2021 SC 544 of the Hon’ble Supreme Court of India  and further in Ravneet Singh V KLM Royal Dutch Airlines (2000) 1 SCC 66 . It is settled law that surveyor’s report has significant evidentiary value unless it is proved otherwise . Reliance has been placed  upon Sikka Papers Ltd Vs. National Insu.Co. Ltd. & Ors, Oriental Insu.Co. Vs. Mehta Wool Store. On merits, the opposite parties have taken the similar pleas as were taken in the preliminary objections, as such there is no need to reproduce the same. While submitting that there is no deficiency in service and while denying and controverting other allegations, dismissal of complaint was prayed.

3.       The complainant also filed rejoinder to the written version filed by the opposite parties  in which  it was denied that the present complaint is liable to be dismissed as alleged. It is settled law as held  in  Hon’ble National Consumer Disputes Redressal Commission, New Delhi in Consumer Complaint No.833 of 2020 titled as M/s.Pyaridevi Chabiraj Steels Pvt.Ltd. Versus National Insurance Company Limited vide which it is held that pecuniary jurisdiction of the District Commission, State Commission or National Commission is to be determined as per the value of the goods or services paid as consideration alone has to be taken and not the value of the goods or service purchased/taken. Therefore, Hon’ble National Commission has held that at the time of entertaining a complaint, actual consideration paid at the time of taking services by the consumer, is to be seen. The same judgement/order as above is relied upon by the Hon’ble State Consumer Disputes Redressal Commission in consumer complaint No.229 of 2020 in its decision dated 14.10.2020 and has returned the complaint for adjudication to the appropriate Consumer Commission. The pecuniary jurisdiction of the District Commission has been enlarged as to ensure that aggrieved consumer gets speedy redressal of his grievances and this fact has been further appreciated by the Hon’ble National Commission and the Hon’ble State Commission in their respective judgements as detailed above. Further reliance has been placed upon Mrs. Poonam Sharma Vs. Institute of Liver & Biliary Sciences and others 2021(3) CLT 601 wherein it has been held that pecuniary jurisdiction – Whether the determinants for pecuniary jurisdiction are consideration paid and compensation claimed? Held- No- On perusal of the provisions of section 47 it would be evident that it is the consideration paid that would determine the pecuniary jurisdiction of a Consumer Commission overruling the position prevalent under the provisions of Consumer Protection Act 1986 where the determinants for pecuniary jurisdiction were consideration paid and compensation claimed. In the present case the amount i.e. premium so paid by the complainant is Rs.5,411/- and thus this Commission has got the jurisdiction to entertain the present complaint. It is denied that it is a clear case of fraud/misrepresentation . 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 have not ruled out any element of forgery or fraud during their investigation and closed the further investigation in which it is specifically mentioned death was caused unfortunate and  it was of no one fault and accident was all of sudden  and also 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. As per the report of First investigator namely Dr. Gurpreet singh of AMABLE CONSULTANCY SERVICES LTD. deputed by the O.P.s who after thorough investigation gave detailed report and have itself recommended the claim against the policy in question to be genuine and payable, who after thoroughly investigated the accident claim of deceased insured and obtained all the requisite documents after visiting the House of the Claimant No.1 and recorded the statement of claimant No.1 who was under great stress and depression due to the death of the husband of the complainant No.1 in young age and even inspite of that she had fully disclosed the true facts which was in her knowledge and  cooperated with the investigator qua information required by the investigator deputed by the opposite parties and she had recorded her statement and provided all the relevant documents to the investigator from time to time as per their demand and the investigator also took some signatures on blank papers on the pretext of settling the claim  in timely manner. It is important to note here that statement of Claimant No.1 clearly established the death of deceased insured was due to an accident and it is strange on the part of the opposite parties who concocted a false story with a view to wriggle out of its legal liability towards the complainants.  The investigator also visited the Civil Hospital, Gurdaspur where the insured deceased immediately taken after the accident and the concerned hospital had issued an OPD Slip i.e EX.C-31 which clearly mentioned that the patient brought dead in hospital on 02/04/2023 at 3 pm c/o head injury. The investigator visited the Concerned Police Station of P.S. Kalanaur, District Gurdaspur vide G.D. No.037 dated 02/04/2023 where the matter was immediately reported on the statement of Avtar Singh son of Sh. Dhanna Singh and after investigation by the Police authorities closed the further investigation by stating the accident happened suddenly and naturally, there is no fault of anyone. The copy of the statement of Avtar Singh is Ex.C-32.  The investigator also visited the Amandeep Hospital, Amritsar for recording the statement of the Mandeep Singh nephew of deceased insured who is an eyewitness of the accident who also disclosed the true facts about the unfortunate accident happened on 02/04/2023. The copy of the statement of Mandeep Singh is Ex.C-33. The investigator also visited the PM CENTER (Post-Mortem, Gurdaspur on 03/04/2023 under PMR no. 32/RD/PMR/CHGSP/2023 and after thorough inspection of the medical record and PMR has been verified as per PMR cause of death is injury to vital organ that is brain  which is sufficient to cause death in ordinary cause. The copy of the Entry recorded in the Register of PMR is Ex.C-35. Even the investigator also collected the information’s from the social media (Newspaper) about the unfortunate accident happened on 02/04/2023 result of which deceased insured died. The copy of the Newspaper cutting is Ex.C-36. The investigator also mentioned in his investigation report as per information gathered during investigation the deceased insured is having no history of depression and any other chronic/critical illnesses or alcohol consumption. That all the information pertaining to the investigation report supported by an affidavit of investigator and the evidence collected from different sources clearly and apparently establish that the cause of death is an accidental one.  As per IRDAI the Accident defines as” Accident - means a sudden, unforeseen, uncontrollable and unexpected physical event to the Insured Person caused by external, violent and visible means occurring under the circumstances described in a Hazard applicable to that person. There was no gross discrepancy in the statement of Nominee and the statement of Mandeep Singh nephew of deceased insured recorded on 25-07-2023, 11-08-2023 but only false and frivolous interpretation made by the opposite parties.  While denying other submissions made by the opposite parties in their written version the complainant has prayed for the relief as sought vide instant complaint.     

Evidence of the parties and Arguments

4.       Alongwith the complaint, complainant has filed her affidavit Ex.CW1/A, copy of policy schedule Ex.C-1, copy of partnership deed Ex.C-2, copy of death certificate Ex.C-3,  copy of GD No. 037 Ex.C-4,copy of OPD slip Ex.C-5, post mortem report Ex.C-6 , copy of legal and valid driving license of DLA Pargat Singh Ex.C-7, copy of repudiation letter Ex.C-8, copy of claim   form Ex.C-9, photographs Ex.C-10 to Ex.C-20, copy of statement of account Ex.C-21,  copy of LIC Insu. policy Ex.C-22, copy of statement of account of complainant No.1 Ex.C-23,  copy of claim paid under PMSBY scheme Ex.C-24. Alongwith rejoinder complainant has filed copies of Income tax Returns Ex.C-24 to Ex.C-26, copy of Farad Haqiqat Ex.C-27, copy of certificate of assets Ex.C-28, copy of statements recorded by police officials Ex.C-29,  copy of  statement made by complainant No.1 to the investigator Ex.C-30, copy of OPD slip  issued by Civil Hospital, Gurdaspur Ex.C-31, copy of statement of Avtar Singh Ex.C-32, copy of statement of Mandeep Singh Ex.C-33, copy of receipt issued  regarding post mortem Ex.C-34, copy of entry recorded in the register of PMR Ex.C-35, copy of newspaper cutting Ex.C-36, copies of statement of Asha worker Ex.C-37  & Ex.C-38.

5.       On the other hand opposite  parties alongwith written version have filed affidavit of Mr. Sahil Saini, Sr. Executive  Operation Ex.OP1,2/1, copies of policy  Ex.OP1,2/2, copy of investigation  report from Amable Consultancy Services Pvt.Ltd. Ex.OP1,2/3, affidavit of Dr.  Gurpreet Singh, Authorized Signatory , Amable Consultancy Services Pvt.Ltd. Ex.OP1,2/4, copy of investigation report by Mohit Rastogi dated 25.10.2023 Ex.OP1,2/5, affidavit of Mohit Rastogi Ex.OP1,2/6, copy of  statement of complainant No.1 Ex.OP1,2/7, copy of questionnaire with statement of complainant No.1 dated 11.8.2023 Ex.OP1,2/8, copy of GD/DDR Ex.OP1,2/9,  copy of discharge summary of co-passenger Mandeep Singh Ex.OP1,2/10, copy of statement of Mandeep Singh Ex.OP1,2/11, copy of clarification letter by Rajinder Kaur Ex.OP1,2/12, copy of repudiation letter  in claim No. SARSUR34 dated 31.3.2024 Ex.OP1,2/13, copy of repudiation letter Ex.OP1,2/14, copy of repudiation letter in claim No. LTPRAC476 dated 31.3.2024 Ex.OP1,2/15, copy of authority letter  Ex.OP1,2/16

6.       We have heard the Ld.counsel for the parties   and have carefully gone through the record on the file .  Ld. Counsel for the complainant suffered a statement that he does not want to file written arguments and the contents of complaint  alongwith exhibited documents be read as part of written arguments. We have also gone through the written arguments submitted by the opposite parties.

Findings

7.       From  the appreciation of the facts and circumstances of the case, there is no dispute that deceased husband of  complainant No.1 , father of complainants No.2 & 3 and son of complainant No.4 namely Sh. Pargat Singh was insured with the opposite parties under the policy plan SARAL SURAKSHA BIMA POLICY vide policy No. SARSUR050022768 for the sum assured of Rs. 60,00,000/- (Rs. Sixty Lacs only) alongwith extra rider (Education grant) providing optional cover of education grant of 10% of base sum insured for per dependent child shall be payable on the admissible claim due to death or permanent total disability of the insured person  . It is the case of complainant No.1 that only Insu. policy schedule was supplied  to the policy holder but no terms and conditions of the policy were ever supplied to the DLA .  It is the case of the complainant that on 2.4.2023 at about 2.40 p.m. , DLA Pargat  Singh was  coming   back  from his sister’s house on his swift car bearing registration No. PB-06-BA-8158 alongwith his cousin Mandeep Singh and when they reached village Khushipur, all of sudden due to accidental slip the abovesaid car struck/hit with the roadside tree (Safaida Tree) and result of which DLA Pargat Singh received serious , multiple and grievous injuries on vital parts of his body and more particularly on his head/brain and Mandeep Singh also got fractures on his leg and due to wuch serious injuries DLA Pargat Singh died on the spot.  In this regard matter was reported to the policy of P.S. Kalanaur, Distt.Gurdaspur vide GD No. 037 dated 2.4.2023 on the statement of Avtar Singh son of Sh. Dhanna Singh and postmortem of DLA Pargat Singh  also got conducted at Civil Hospital, Gurdaspur, copy of GD  No. 037 is Ex.C-4, copy of  post mortem report is Ex.C-6. Opposite parties were also informed , who deputed number of investigators against the provisions of IRDAI, who recorded the statement of complainant No.1 and complainant No.1 provided all the relevant documents to the investigator from time to time as per their demand and investigator also took some signatures on blank papers on the pretext  of settling the claim   . However,  Opposite parties vide letter dated 31.3.2024  repudiated the  claim of the complainants on the ground that “during investigation the opposite party noted multiple discrepancies and as such the claim stands repudiated under clause No. F.II.15. It is also the case of the complainant that claim in respect of damaged vehicle   i.e. Swift car bearing registration No PB-06-BA-8158 was also  processed by the Insu. Company being total loss  basis and credited the claim amount in the bank account, copy of bank account statement is Ex.C-21. Similarly DLA Pargat Singh was also having one LIC Insu. policy and LIC has also processed  the claim amount in the bank account of complainant No.1 on 10.5.2023  and copy of LIC policy is Ex.C-22 and statement of account of complainant No.1 is Ex.C-23. One accident claim was paid by LIC under PMSBY scheme copy of which is Ex.C-24. Opposite parties No.1 & 2 have neither provided the investigation report nor has given any explanation of discrepancies pointed out by the subsequent investigator . Ld.counsel for the complainants vehemently contended that the aforesaid act of the  opposite parties in repudiating  the  genuine claim of  complainants  is an act of deficiency in service, malpractice, unfair trade practice and has caused lot of mental agony, harassment, inconvenience besides financial loss to the complainant.

8.       On the other hand opposite parties repelled the aforesaid contentions of the complainants and raised certain pleas such as deceased insured Mr. Pargat Singh applied two different proposals for availing two benefit policies from the opposite parties through his intermediary Ms. Sadhika Mahajan on 10.8.2022 to the tune of Rs. 80 lacs which raises suspicion as a normal prudent man with a gainful annual income of only Rs. 6 lacs would not generally avail coverage for such a huge amount . It is further submitted that   this Hon’ble Commission has no pecuniary jurisdiction to try, entertain and decide the present complaint as the total claimed amount of Rs. 82,50,000/- which exceeds Rs. 50 lacs  . The further submission taken by the opposite parties is  that complicated question of law & facts are involved in the present complaint which requires examination and cross examination of witness and voluminous evidence  which is not possible in summary proceedings under the  CPAct 2019. The main ground taken by the opposite parties while repudiating the claim is that during investigation opposite parties noted multiple discrepancies such as complainant No.1 in her complaint has stated that due to accidental slip, the car was struck /hit with the roadside tree, which is in contradiction to her statements procured during the investigation. As such the claim of the complainants have rightly been repudiated and there is no deficiency in service on the part of the opposite parties.

9.       This Commission has given thoughtful consideration to the facts of the present case  and the moot questions involved in this case (i) whether terms and conditions were supplied to the deceased life assured (ii) whether this Commission has pecuniary jurisdiction (iii) whether  this Commission can decide this complaint as the opposite parties have taken a preliminary objections that complicated question of law & facts are involved in the present complaint which requires examination and cross examination of witness and voluminous evidence (iv) whether the ground taken by the opposite parties while repudiating the claim is genuine one.

10.     First of all the point No. (i) whether  terms and conditions were supplied to the deceased life assured is to be taken  and to meet with thispoints this Commission has perused the case file as well as the pleadings of the parties.  The contention of the complainants is that only policy schedule was supplied and no terms and conditions were ever supplied to the deceased life assured. Opposite Parties could not produce  any evidence to prove that terms and conditions of the policy were ever supplied to  the husband of the complainant  No.1 when and through which mode? It has been held by Hon’ble National Commission, New Delhi in case titled as The Oriental Insurance Company Limited Vs. Satpal Singh & Others 2014(2) CLT page 305 that the insured is not bound by the terms and conditions of the insurance policy unless it is proved that policy was supplied to the insured by the insurance company. Onus to prove that terms and conditions of the policy were supplied to the insured lies upon the insurance company.

11.     The other point for consideration is whether this Commission has pecuniary jurisdiction. No doubt the  relief sought by the complainants is to the tune of Rs. 82,50,000/- which exceeds Rs. 50 lacs   but for obtaining the policy in dispute deceased life assured admittedly paid the premium of Rs. 5411.71, as such  while deciding the case  this Commission has only  to see what premium amount has been paid by the insured  and not the sum assured. Reliance in this connection has been placed upon M/s. Maharani of India Vs. Branch Mgr. United India Insu. Co. Ltd. 2018(2) CLT 301 of the Hon’ble National Commission, New Delhi wherein it has been held that when an Insurance policy is taken by a person  he  pays a premium to the insurer for hiring or availing its services- It is the premium paid by the insured to the insurer and not the extent of the sum insured which constitutes the agreed consideration and therefore in my opinion, it is the premium paid to the insurer which when added to the compensation claimed in the complaint would determine the pecuniary jurisdiction of this Commission- The extent of  the sum assured would have no bearing on determination of the pecuniary jurisdiction of a consumer Forum.” Further reliance has been placed upon by the Hon’ble National Consumer Disputes Redressal Commission, New Delhi in Consumer Complaint No.833 of 2020 titled as M/s.Pyaridevi Chabiraj Steels Pvt.Ltd. Versus National Insurance Company Limited vide which it is held that pecuniary jurisdiction of the District Commission, State Commission or National Commission is to be determined as per the value of the goods or services paid as consideration alone has to be taken and not the value of the goods or service purchased/taken. Same view has been taken  in Mrs. Poonam Sharma Vs. Institute of Liver & Biliary SDciences and others 2021(3) CLT 601 wherein it has been held that Pecuniary jurisdiction – Whether the determinants for pecuniary jurisdiction are consideration paid and compensation claimed ? Held- No- On perusal of the provisions of section 47 it would be evident that it is the consideration paid that would determine the pecuniary jurisdiction of a Consumer Commission overruling the position prevalent under the provisions of Consumer Protection Act 1986 where the determinants for pecuniary jurisdiction were consideration paid and compensation claimed. The aforesaid law squarely covers the case of the complainants as in the present case deceased life assured only paid the premium of Rs. 5411.71 and when the compensation claimed by the complainant i.e. Rs. 10,00,000/- is added  in the premium amount , that amount does not exceeds Rs. 50 lacs   , as such this Commission has got the jurisdiction to entertain the present complaint.

12.     The other point raised by the opposite parties is that  this Hon’ble Commission has no jurisdiction to try, entertain and decide the present complaint as complicated question of law & facts are involved in the present complaint which requires examination and cross examination of witness and voluminous evidence. But we are not agreed with this plea taken by the opposite parties our own Hon’ble State Consumer Disputes Redressal Commission has placed reliance upon  Sh. Raminder Pal Singh Vs. ICICI Bank in First Appeal No. 233 of 2019 of the Hon’ble Supreme Court in case “Dr. J.J. Merchant & Ors. Vs. Shrinath Chaturvedi  2002(2) CPC 640 in which it has been held that the Consumer Forums should not shirk their responsibility simply on the ground that some intricate matters are involved in the case. All the Foras are presided by experienced Judicial  Officers and it is expected of them to decide the cases on merits, on the basis of prima facie evidence on record.  Reliance has also been placed upon “Shiv Kumar Agarwal Vs. Arun Tonden & Anr.” 2007(2) CPC 129 (NC) in which it was observed by the Hon’ble National Commission  in para 5 as follows:-

“5 We heard the learned counsel for the petitioner and perused the material on record. Like before the State Commission, the learned counsel for the petitioner argued before us that this case involves complicated questions of fact and law and will need expert evidence which is not possible in the summary procedure adopted by the Consumer Fora. After seeing the complaint, written version as also the judgements of the Hon’ble Supreme Court in the case of Dr. J.J.Merchant and Ors. Vs. Shrinath Chaturvedi and other catena of judgements, we are of the view that Consumer Forum which is headed by Senior Judicial Officers, are capable of dealing with even complex questions. The consumer Protection Act, 1986 under Section 13 provides for calling for expert evidence, if necessary.”

13.     However the main plea taken by the opposite parties while repudiating the claim is that  opposite parties during investigation noted multiple discrepancies such as complainant in her complaint has stated that due to accidental slip, the car was struck /hit with the roadside tree, which is again in contradiction to her statements procured during the investigation, therefore, being unable to admit the claim thereby repudiated the same as per terms and conditions of the policy clause No. F.1.7. But we are not agreed with this ground taken by the opposite parties while repudiating the claim as   the accident was admitted  and in this regard the complainant has placed on record  copy of GDR Ex.C-4 and postmortem of DLA Pargat Singh  also got conducted at Civil Hospital, Gurdaspur, copy of  post mortem report is Ex.C-6. Opposite parties were also informed , who deputed investigator  who  after visiting the Civil Hospital, Gurdaspur where the insured deceased immediately taken after the accident , Concerned Police Station of P.S. Kalanaur, District Gurdaspur vide G.D. No.037 dated 02/04/2023, Amandeep Hospital, Amritsar for recording the statement of the Mandeep Singh nephew of deceased insured who is an eyewitness of the accident who also disclosed the true facts about the unfortunate accident happened on 02/04/2023,  post mortem CENTER , Gurdaspur on 03/04/2023 under PMR no. 32/RD/PMR/CHGSP/2023 and after thorough inspection of the medical record and PMR has been verified as per PMR cause of death is injury to vital organ that is brain  which is sufficient to cause death in ordinary cause. The  investigator also mentioned in his investigation report as per information gathered during investigation the deceased insured is having no history of depression and any other chronic/critical illnesses or alcohol consumption  and found that death was caused unfortunate and  it was of no one fault and accident was all of sudden  and also 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.  However the opposite parties instead of paying the claim  appointed second surveyor  who  gave his report Ex.OP1,2/5. But once the surveyor appointed by the opposite parties itself gave its report  and recommended to pay the claim, what compelled the opposite parties to appoint second surveyor which is also against the  provisions of IRDA. Now the question arises as to whether the opposite parties could appoint another surveyor particularly when the earlier surveyor  namely Dr. Gurpreet Singh of Amable Consultancy Services Ltd. appointed by the opposite parties themselves  has already submitted his report and recommended the claim to be genuine  and  the act of the opposite parties in appointing second surveyor by discarding the report submitted by their own appointed first surveyor is against the provisions of IRDA. Reliance in this connection has been placed upon M/s. Sparkling Traders Pvt.Ltd. Vs. M/s. New India Assurance C o.Ltd. 2015(1) CLT 558 (NC), wherein it has been laid down that after getting first surveyor’s report there was no occasion to appoint 2^nd surveyor without any cogent reason. The commission in complaint No. 73 of 2002 M/s. Jagannatha Poultries Vs. New India Assurance Co.Ltd. while placing reliance on judgement of Hon’ble Apex Court reported in AIR 2010 SC 3035-New India Assurance Co.Ltd. Vs. M/s. Protection Manufacturers Pvt.Ltd. observed  as under :-

“The submissions of Mr.Piyush Gupta in regard to section 64UM of the Insurance Act, 1938, are also of substance, as the Appellant-insurance company should have applied to the Regulatory Authority under the Act for a second opinion instead of appointing M/s. J.Basheer & Associates for the said purpose unilaterally. The reports submitted by M/s. J.Basheer & Assocaties are liable to be discarded on such ground as well and rightly held that though it is permissible to appoint 2^nd surveyor to assess the loss but this must be for given reasons and only through the auspices of the Regulatory Authority i.e. IRDA . Admittedly, in the case in hand neither any cogent reason has been given by opposite party No.1 for appointing 2^nd surveyor nor 2^nd surveyor has been  appointed through IRDA nor report of 2^nd surveyor has been placed on record and in such circumstances no reliance can be placed on the report of 2^nd surveyor M/s. J.Basheer & Associates. Report of the 2^nd surveyor was not relied by Hon’ble Apex Court in the judgment of M/s. Protection Manufacturers PVt. Ltd. (Supra). If report of 2^nd surveyor M/s. Protection Manufacturers Pvt.Ltd is discarded then on the basis of report of surveyor M/s. S.S.Kashyap, complainant was entitled to get compensation of Rs. 5,81,900/-.

14.     Moreover once the vehicle was duly insured and the accident occurred during the currency of the policy period the opposite party cannot throw the matter in dustbin by taking such illegal pleas which was taken in the instant complaint, whereas the complainant has brought the sufficient evidence  and the Investigator appointed by the opposite parties recommended the claim to be genuine one . Moreover as per IRDAI the Accident defines as” Accident - means a sudden, unforeseen, uncontrollable and unexpected physical event to the Insured Person caused by external, violent and visible means occurring under the circumstances described in a Hazard applicable to that person. The act of the opposite parties in repudiating the genuine claim of the complainants amounts to deficiency in service  and the opposite parties are  liable to make good the loss by paying the claim amount to the complainant.

15.     Regarding quantum of claim  vide policy schedule Ex.C-1 the deceased life assured was  duly insured for the sum assured of Rs. 60,00,000/- as well as  was also covered  for education grant of 10% of base sum insured for her dependent child which comes to Rs. 12,00,000/-. As the deceased life assured died due to accident, as such the  complainants being legal heirs of deceased life assured  Sh . Pargat Singh are entitled to the sum assured of Rs. 60,00,000/- as well as Rs. 12,00,000/- (i.e. 10% of base sum insured for per dependent child) and the opposite parties are liable to pay the aforesaid amount to the complainants in equal share.

16.     In view of the above discussion, we allow the complaint  and the opposite parties are directed to  reimburse the claim amount of Rs. 60,00,000/- as sum assured as well as Rs. 12,00,000/- as education grant  of his dependent child i.e. in all Rs. 72,00,000/- to the complainants in equal shares by taking their affidavits as well as Adhar cards of the complainants. So far as compensation  is concerned , though admittedly compensation term has not been explained in the Consumer Protection Act, however  since this  Act is based on principle of equity, good concise  and natural justice and the Commission is empowered to provide compensation after assessing the facts of each case. In the present case  the conduct of the opposite parties is so callous  as despite recommendation of the surveyor appointed by the opposite parties regarding the claim lodged by the complainants is genuine, they have appointed second surveyor and  lastly repudiated the claim on false and frivolous grounds and compelled the complainant to knock the door of this Commission again on which the complainants who are the sufferer due to the death of  Pargat Singh at such a young age   and by not paying the claim, the complainants have to face lot of harassment at the hands of the opposite parties, as such opposite parties are also liable to pay exemplary compensation to meet the ends of justice. This Commission relied upon the latest law on this point of compensation i.e. the  Hon’ble Supreme Court in case  Amitabha Dasgupta Vs. United Bank of India and others  AIR 2021 SC (Civil) 1457 wherein it has been held that “ Deficiency in service- Duty of care  should be exercised by bank irrespective of application of laws of bailment to contents of locker- Bank inadvertently broke customer’s locker, without giving prior notice, inspite of clearing pending dues by him- Bank acted in blatant disregard to responsibilities owned to customer as service provider- Case of gross deficiency in service- Imposition of costs of Rs. 5,00,000/- on bank, would be appropriate compensation to customer.”

17.       Reverting back  to the present case, since it was term Insurance, hence deceased has taken  the policy only to meet the eventuality of his untimely death but the opposite party since has acted arbitrarily  while rejecting the claim of the complainant and after asking all the circumstances stated as above, this Commission deem it fit to award compensation of Rs. 1,00,000/- as well as Rs. 10000/- as litigation expenses to the complainants  in equal shares  Compliance of this order be made within 45 days from the date of receipt of copy of this order ; failing which complainants shall be further entitled for interest @ 7% p.a. on the whole awarded amount from the date of filing of this complaint till its realization  Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this commission.