ORDER

Shri A.K.Patra,President:

1. The Complainant has filed this complaint alleging negligence& deficiency of service on the part of O.Ps on account of non release of insurance benefit under a group Health Insurance Product vide Policy No.345600/48/2019/1080 and prayed for an order directing the opposite party No.1 to reimburse the medical expenses of Rs.1,03,951/- and further be pleased to award compensation of Rs.15000/- and cost of litigation.
2. Heard. Perused the material on record. We have our thoughtful consideration to the submission of  learned counsel for the parties .
3. Brief fact of the complaint is that, the petitioner has taken a group Health Insurance Product vide Policy No.345600/48/2019/1080 from the opposite party No.1 (one) through Junagarh Branch of Punjab National Bank covering his entire family including Yogesh Kumar Agrawal for sum insured Rs.5,00,000/-.Tthe Opposite party No.2 is approve TPA. During the currency of the above policy the son of the petitioner Yogesh Kumar Agrawal suffered stomach pain for which he contacted Sri, Moolchand Khairati Ram Hospital and Ayurveda Research Institute, New Delhi on 04.11.2019 wherein he was diagnosed having stone in his stomach. He has spend an amount of Rs.14,030/-.there after the petitioner approached Primus Super Specialty Hospital for the required operation on 09.11.2019 and as per advice of the treating doctor Yogesh Kumar Agrawal was admitted therein on 11.011.2019 and spent Rs.88,771/-and as the petitioner has said mediclaim policy the above hospital lodged claim for cashless  treatment of Yogesh Kumar Agrawal on 09.11.2019 for Rs.88,771/-but it was denied by the Opposite party No.2 for which  the petitioner paid the bill amount of Rs.88,771/-to the hospital authority .Insured Yogesh Kumar Agrawal was discharged on 13.11.2019 after the required operation .As per policy condition, the complainant  is entitled for the entire expenses incurred for the treatment of Yogesh Kumar Agrawal i.e. Rs.1,03,951/- which includes treatment expenses and pre hospitalization charges. The opposite party have arbitrarily denied the claim of the petitioner which is clearly unfair trade practice and deficient in service.
4. The  complainant .to substantiate his claim filed the following documents;-

1. Copy of policy bearing No.345600/48/2019/1080.
2. All the medical bills of Sri Mool Chand Khairati Ram Hospital.
3. All the medical bills of Primus Super Specialty Hospital .
4. Averment of the complainant are supported by an affidavit of the complainant.

5. On being notice the O.Ps have appeared through their Learned counsel but failed to filed written version so also no rebuttable evidence is adduced is adduced to by the ops though taken part in the further proceeding of this complainant.
6. Here the doctrine of non –traverse will rightly applicable as non of the allegation made by the complainant are ever disputed or traversed by the O.P in any manner .The opposite party have neither    disputed nor produce any evidence contrary to the averment of the complainant which in terms is a clear admission of facts of the complaint and the same need not proved as per Sec 58 of Indian evidence Act. Law is well settled that  every allegation of facts in the complaint if not denied specifically or by necessary implication , or stated to be admitted in the pleading of the O.P shall be taken to be admitted accept as against a person disability . Where the O.p has not filed a pleading it shall be law full for the court to pronounced judgment on the basic of the fact contend in the plaint except as against the person under a disability (Reliance placed upon the judgment of the Hon’ble Supreme Court passed in M.Venkataramana Hebbar Vs M. Rajagopal Hebbar & Others, Lohia Properties (P) Ltd Vs. Atmaram Kumar).
7.  In the light of above said discussion and settled principle of law the complainant is entitled for insurance benefit insurance benefit under a group Health Insurance Product vide Policy No.345600/48/2019/1080 and ops are arbitrarily  denied as such   we are of the considered view that there is deficiency in service on the part of O.Ps towards the complainant which caused him mental agony and financial loss as such the complainant is entitled to be compensated by the O.Ps.. Hence it is order.

ORDER

 The O.P No 1(one) is directed to pay  the medical expenses of Rs.1,03,951/- under the said  group Health Insurance Product vide Policy No.345600/48/2019/1080 to the complainant with interest @ 9% p.a from the date of filling if this complainant i.e. 09.12.2020 till its realization  and further directed to pay Rs.10,000/ towards  cost of litigation to the complainant within four weeks from the date of received of this order failing which the Ops are liable to pay  interest @ 12% over the awarded amount till its realization.

This consumer Complain is partly allowed in above terms.

The pending application if any is also stands disposed off.

Dictated and corrected by me.   

 President

I   agree.

 Member                                                             President

Pronounced in open Commission today on this   12^th January 2023  under the seal and signature of this Commission.

Copy of this judgment be provided to the parties free of cost .The judgment be uploaded forth with on the website of the Commission for the perusal of the parties. Ordered accordingly .

Member                                                      President