IN THE CIRCUIT BENCH OF THE TAMILNADU STATE CONSUMER DISPUTES REDRESSAL COMMISSION, MADURAI Present Date of appeal filed: 31.07.2018 THIRU. S.KARUPPIAH, PRESIDING JUDICIAL MEMBER F.A.No.45/2019 MONDAY, THE 04^th DAY OF SEPTEMBER 2023.

1. The Branch Manager, United India Insurance Company Limited, South Main Street, Thanjavur Town.

2. The Branch Manager, M.D.India Health Care Service (TPA)

Private Limited, No.27, Laxmi Towers, 3rd Floor, Dr.Radhakrishnan Salai, Mylapore, Chennai-9. 1st & 2nd Appellants/1st & 2nd Opp.Parties -Vs-

1. V.Balraj, No.1217, Annai Illam, Thilagar Street, Thillai Nagar, Pookkara Vilar Road, Thanjavur – 613 006. 1st Respondent/Complainant

2. The Manager, Meenakshi Hospital, No.244/2, Trich Main Road, New Bus Stand, Thanjavur. 2nd Respondent/3rd Opposite Party

3. Additional Treasury Officer, Pension Disbursing Officer, District Treasury, Thanjavur. 3rd Respondent/4th Opposite Party

4. The State of Tamil Nadu, Rep.by its District Collector, Collectorate, Thanjavur. 4th Respondent/5th Opposite Party Counsel for Appellants-1&2/Opp. Parties-1&2 : M/s.A.Shajahan, Advocate.

Counsel for Respondent-1/Complainant : Called Absent.

Counsel for Respondent-2/Opposite Party-3 : K.M.Thirupathy, Advocate.

Counsel for Respondents-3&4/Opp.Parties-4&5 : Mr.D.Makson Lobo,Govt.Pleader.

Aggrieved by the award passed by the District Consumer Disputes Redressal Commission, Thanjavur made in C.C.No.49/2015, dated 25.05.2018 the opposite parties 1&2 preferred this appeal. This appeal coming before me for final hearing on 14.08.2023 and upon perusing the material records, this Commission made the following: ORDER THIRU.S.KARUPPIAH, PRESIDING JUDICIAL MEMBER.

1. The Facts:

The complainant one V.Balraj is a retired Government School Teacher and he joined in the ‘New Health Insurance Scheme for pensioners-2014”. As a pensioner he was covered by the Insurance Scheme. Whileso the complainant was admitted in the third opposite party’s Meenakshi Hospital on 17.01.2015 for his alleged stomach pain. He was diagnosed as ‘Gangrenous Cholecystitis (Empyema) Ileal Stricture-Sub Acute obstruction and decided to undergo surgery by using the procedure of Laparotomy-open Cholecystectomy + Stricturoplasty. Immediately on 17.01.2015 the complainant informed the third opposite party about the insurance particulars and to make a request to the second opposite party for cashless authorization. The third opposite party also made the request on 19.01.2015, the second opposite party repudiated the request stating that the “procedures not covered”. Thereafter, the complainant spent Rs.2,00,482/- and in spite of repeated letters the first and second opposite parties who are the Insurance Company and the Administrator, and the fourth and fifth opposite parties who are the Government Officers in-charge of the scheme, failed to refund the insurance claim. Hence the complaint is filed claiming medical reimbursement amount of Rs.2,00,482/- and compensation of Rs.10,00,000/- and also cost of the proceedings.

2. The first opposite party in their counter has stated that the complainant is put into strict proof that he is eligible for Insurance Scheme and he is eligible to cashless treatment. As per the scheme G.O.Ms.No.171 only certain hospital and certain medical treatment alone eligible for cashless facilities. As per the scheme the complainant is not entitled to get reimbursement. Hence the complaint is liable to be dismissed.

3. The third opposite party in their written version has stated that there is no negligence on their part in forwarding the claim or giving treatment to the complainant. The complainant was admitted for Gangrenous cholecystitis (Empyema) Ileal Stricture- open cholecystectomy + stricture plasty. Immediately in order to save the complainant from danger the surgery was performed and he was discharged on 23.01.2015. He again came up for review subsequently and there is no further complication. So the complaint is liable to be dismissed against them.

4. The fo