Ritu Bahri, J. - (1.) The Oriental Insurance Company has challenged the Award dated 27.9.2013 passed by the Permanent Lok Adalat, Public Utility Services, Faridkot.
(2.) Smt. Sangita Sharma suffered an ailment on 22.9.2012 and was admitted in Fortis Escort Hospital, Amritsar on 23.9.2012. She was discharged on 29.9.2012 and spent a sum of Rs. 1,59,688/- as per the bills Ex.C-16 and C-17. She was diagnosed in the Hospital of having a hole in her heart. Her claim was rejected by the Insurance Company on the ground that she had undergone a LSCS (Caesarean operation) 3 days earlier and this operation was the cause of a subsequent ailment. No treatment was given to Sangita Sharma during her hospitalization in Fortis Hospital. As per the Insurance Policy under which the claim was made it did not cover any expenditure occurred on a disease traceable to pregnancy, child birth, miscarriage or Caesarean Section or Abortion etc. Hence, her case was rejected under Clause 4.13 of Exclusion Clauses of the policy. Reference had been made to a prescription slip of Dr. H.P.Singh dated 28.9.2012 of Fortis Hospital which reflects that she had undergone Caesarean operation 3 days in advance. The claim of respondent No.3 has been allowed keeping in view that there was no evidence led by the Insurance Company to prove that the hole in the heart was a direct cause of pregnancy and Caesarean operation of the claimant. There was no expert evidence produced by the Insurance company to this effect. In the diagnosis slip the fact of Caesarean operation has been mentioned in the history records only as a matter of record and not cause of disease (hole in heart) for which she was admitted in the hospital. The payment of the bills C-16 and C-17 was not disputed by the Insurance Company, therefore, the case of the claimant was not covered under Clause 4.13 of the Exclusion Clauses of the policy. The hole in the heart could not be a disease related to pregnancy, child birth, miscarriage or Caesarean Section or Abortion etc. The approach of the Permanent Lok Adalat is in conformity with the object of Section 22-C(8) of the Legal Services Authorities Act, 1987 which reads as under:- "22-C(8) Where the parties fail to reach at an agreement under sub-section (7), the Permanent Lok Adalat shall, if the dispute does not relate to any offence, decide the dispute."
(3.) Initially, when the application was made an attempt was made that the Insurance Company would settle the claim. The fact that Smt. Sangita Sharma was admitted in Fortis Hospital and paid the bills C-16 and C-17 was not disputed. It is only at that stage that the Lok Adalat invoking the provisions of Section 22-C(8) of the Legal Services Authorities Act, 1987 has gone ahead to decide the matter.;