Punjab-Haryana High Court
The Oriental Insurance Co vs Permanent Lok Adalat on 27 January, 2014
Author: Ritu Bahri
Bench: Ritu Bahri
C.W.P. No. 1472 of 2014 [ 1 ]
IN THE HIGH COURT OF PUNJAB & HARYANA, CHANDIGARH
C.W.P. No. 1472 of 2014
Date of Decision:27.1.2014
The Oriental Insurance Co., Chandigarh........... Petitioner
Versus
Permanent Lok Adalat, Faridabad and others ...Respondents
Coram: Hon'ble Ms. Justice Ritu Bahri
1.To be referred to the Reporters or not?
2. Whether the judgment should be reported in the Digest?
Present: Mr. V.Chaudhri, Advocate
for the petitioner.
...
RITU BAHRI, J.
The Oriental Insurance Company has challenged the Award dated 27.9.2013 passed by the Permanent Lok Adalat, Public Utility Services, Faridkot.
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 `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 Kaur Rupinder 2014.02.28 11:00 I attest to the accuracy and integrity of this document Chandigarh C.W.P. No. 1472 of 2014 [ 2 ] 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 Kaur Rupinder 2014.02.28 11:00 I attest to the accuracy and integrity of this document Chandigarh C.W.P. No. 1472 of 2014 [ 3 ] 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."
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.
A Division Bench of this Court in M/s Paras Holidays Pvt. Ltd. and others v. State of Haryana and others 2008 (4) R.C.R. (Civil) 367 had an occasion to examine a case where the Award of the Lok Adalat was under
challenge. In this case tourists had made a case of return of the amount paid to the travel agent which they had made after booking a tour for Europe. The tourists had cancelled their booking much in advance. The request for refund of the amount was denied by the travel agent as the amount stood Kaur Rupinder 2014.02.28 11:00 I attest to the accuracy and integrity of this document Chandigarh C.W.P. No. 1472 of 2014 [ 4 ] forfeited. A further request for making arrangements for the next trip was also declined invoking the provisions of Section 22-C(8) of the Legal Services Authorities Act, 1987 and direction given by the Permanent Lok Adalat for refunding the amount was upheld by the Division Bench. In paragraph 4 of the judgment it has been observed as under:-
"The second argument on merits is equally devoid of substance because firstly under Section 22-A of the Act, award of the Lok Adalat has to be regarded as final and it cannot be called in question in another original suit, application or execution proceedings. Although it cannot be concluded that this Court under Article 226 could not interfere yet the scope of interference in such type of matters is extremely limited. This Court may interfere in cases where a totally arbitrary and unreasonable order has been passed by the Lok Adalat."
In the present case, the claimant was admitted in Fortis Hospital and was diagnosed hole in the heart and payment was made vide Bills C-16 and C-17 for the amount of `1,59,688/-. This fact is not disputed by the Insurance Company. The claim is being rejected on the ground that this disease is being related to the Caesarean operation which was conducted 3 days prior to her admission in the Kaur Rupinder 2014.02.28 11:00 I attest to the accuracy and integrity of this document Chandigarh C.W.P. No. 1472 of 2014 [ 5 ] Fortis Hospital and as per the policy respondent No.3 could not claim any expenses incurred on disease traceable to pregnancy, child birth, miscarriage or Caesarean Section or Abortion etc. and it fell under Section 4.13 of the Exclusion Clauses of the policy. There was no expert evidence led by the Insurance Company that this disease was related to the above said clause. Therefore, a direction was given to make the payment after invoking Section 22-C(8) of the Legal Services Authorities Act, 1987.
No case for interference in the Award dated 27.9.2013 passed by the Permanent Lok Adalat, Public Utility Services, Faridkot, is made out.
The writ petition is dismissed.
( RITU BAHRI ) JUDGE 27.1.2014 rupi Kaur Rupinder 2014.02.28 11:00 I attest to the accuracy and integrity of this document Chandigarh