Appellants claim for reimbursement for cataract surgery was reduced to Rs. 30,000 - CIC: United India Insurance Co to furnish a detailed breakdown of the medical expenses incurred, along with all relevant documents and justifications for the decisions

O R D E R

FACTS

The Appellant vide his RTI application sought information on following points:

1. Please provide copy of the complete file pertaining to Claim No GUR-0223-CL-0004480 as per records.
2. Please provide copy of the complete notings pertaining to Claim No GUR-0223-CL-0004480 as per records.
3. Please provide copy of the detailed GIPSA package with complete breakdown on the types of lenses, treatment, procedure or any other for Catararact surgery through MICS procedure as per records.
4. Please provide copy of the detailed GIPSA package with complete breakdown on the tpes of lenses, treatment, procedure or any other for Catararact surgery through ANY/ ALL OTHER procedure as per records.
5. Please provide details on number of claims for cataract surgery through MICS procedure received by you from 01.10.2022 till 23.02.2023 as per records.
6. Please provide details on number of claims where the insurer has paid above Rs 30,000/- towards claim for cataract surgery through MICS procedure from 01.04.2022 till 23.02.2023 as per records
7. Please provide complete contact details of the disciplinary authority to whom complaint against TPA ooicers can be raised as per records.
8. Please provide copy of any guidelines / rules/ OMs/ standing ordes/ directions or any such (to be read as ejusdem generis) laying down the exceptions when the payments beyond GIPSA package can eb made to the claimant as per records. If no such guidelines / rules/ OMs/ standing ordes/ directions or any such (to be read as ejusdem generis) exist on records, the PIO is requested to kindly provide clear response stating the same as per records.
9. Please provided copy of any guidelines / rules/ OMs/ standing ordes/ directions or any such (to be read as ejusdem generis) strictly laying down the restriction on payments beyond GIPSA package to the claimant as per records. If no such guidelines / rules/ OMs/ standing ordes/ directions or any such (to be read as ejusdem generis) exist on records, the PIO is requested to kindly provide clear response stating the same as per records.

The CPIO vide letter dated 27-04-2023, furnished a reply to the Appellant. Dissatisfied with the reply received from the PIO, the Appellant filed a First Appeal. The FAA vide order dated16-05-2023 upheld the reply of the CPIO. Thereafter, the Appellant filed a Second Appeal before the Commission.

HEARING:

Facts emerging during the hearing:

The following were present:

Appellant: The appellant attended the hearing in person.

Respondent: The respondent Shri Sushma Thakkar, Manager and Mr. Shanta Halder, Regional Manager, United India Insurance Co. Ltd. attended the hearing in person.

The Appellant reiterated the contents of the RTI application and submitted that partial, false, and misleading information was furnished to him by the CPIO. The appellant informed that his spouse was treated at Dr. Shroffs Charity Eye Hospital, for Cataract Surgery through an MICS procedure. The Discharge summary claim for the same, he stated, was raised with Insurers which was restricted to Rs. 30,000 by TPA as per terms of the insurance policy. He said he was entitled to Rs 50,000/- i.e. 10% of sum insured but the insurers restricted reimbursement as per GIPSA whereas no such restriction was in the policy and also the insurers failed to share complete details of GIPSA which apparently had lenses of lower specifications than the ones actually installed by the doctor in the surgery. He also submitted that the RTI revealed that the Insurer can pay above GIPSA if the lens used was of higher specification. But In spite of representation to Insurers, he said, they refused to remit the amount. The appellant further stated that the CPIO had only provided a list of certain surgeries and the packages but no detailed breakdown on the same was provided.

The appellant also informed that the FAA also failed to provide the detailed breakup as was sought by the appellant. Further, the appellant requested that the Commission to pass appropriate orders to ensure the provision of the information sought was provided to him in complete transparency for which the appellant said he relies not only on the contents of the appeal but also on the arguments and averments that the appellant shall lead before the Hon'ble Commission on the date of hearing.

The Respondent present during the hearing submitted that a suitable response in accordance with the provisions of the RTI Act, 2005, had already been furnished to the Appellant. The respondent further stated that the complainant had also approached the Ombudsman office and an award was received for compliance the department made the payment to the appellant on 17.10.2023 and they have provided the UTR No. in their documents to the CIC office. Further, the respondent informed that the appellant had filed a complaint before the Hon’ble Ombudsman who vide order dated 29.09.2023 passed the directions to take up the matter with the Hospital for a refund of the excess amount charged by them to the complainant or settle the claim for balance amount as per policy terms and conditions for cataract surgery. Further, the respondent also agreed to settle the claim for the balance amount as per the directions of the Hon’ble Ombudsman.

DECISION:

Keeping in view the facts of the case and the submissions made by both the parties and after perusal of the documents available on record, the Commission observes that the Appellant sought detailed information regarding the medical expenses incurred on a cataract surgery, which falls well within their right to access under the RTI Act, 2005. However, the Appellant has repeatedly raised concerns about receiving partial, false, and misleading information, and his pursuit of complete and accurate details is a matter of paramount importance.

The Commission also observes that the Appellant's claim of entitlement to Rs. 50,000 for the cataract surgery as per their insurance policy is a significant matter that deserves immediate attention. The appellant also alleged that the insurers restricted reimbursement as per the GIPSA, which, according to the Appellant, was not a part of the policy. Furthermore, the Appellant has pointed out discrepancies regarding the lenses used in the surgery, indicating that the insurers failed to provide complete information. Notably, the RTI revealed that insurers can pay above GIPSA if a lens of higher specifications is used.

Furthermore, it is essential to recognize the larger public interest in this matter. The transparency and accuracy of information related to medical insurance claims and expenses are of great concern to the general public. In an age where healthcare costs are rising, individuals rely on their insurance policies for financial support during medical procedures. The lack of transparency and potential discrepancies in the process can significantly affect public trust in the insurance system.

In view of the above, the Commission must stress the importance of immediately addressing the Appellant's concerns and ensuring full disclosure of the requested information, in accordance with the provisions of the RTI Act, 2005. Therefore, the Commission directs the CPIO of United India Insurance Company Limited to furnish the requested information including a detailed breakdown of the medical expenses incurred during the cataract surgery, along with all relevant documents and justifications for the decisions made within 21 days from the receipt of this letter. Moreover, the information should be provided to the Appellant free of cost, in line with the principles of transparency and accountability embedded in the RTI Act.

The Commission would like to emphasize that this direction is not just a response to the Appellant's requests but also a step towards upholding the principles of open governance, accountability, and transparency that are central to our democratic values.

The Appeal stands disposed of accordingly.

(Uday Mahurkar)

Information Commissioner

Citation: Mr. Ajay Kumar Gupta v. United India Insurance Co. Ltd., CIC/UIICL/A/2023/632292-UM; Date of Decision: 01.11.2023