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Central Information Commission

Azad Singh vs Ministry Of Health & Family Welfare on 27 October, 2017

                    CENTRAL INFORMATION COMMISSION
                   August Kranti Bhawan, Bhikaji Cama Place,
                              New Delhi-110066
                                                 F. No. CIC/YA/A/2016/002169

Date of Hearing                      :   14.09.2017
Date of Decision                     :   16.10.2017
Appellant/Complainant                :   Mr. Azad Singh
Respondent                           :   PIO
                                         CMO I/C (Hospital Cell)
                                         O/o the Additional Director (HQ),
                                         CGHS

Information Commissioner             :   Shri Yashovardhan Azad

Relevant facts emerging from appeal:

RTI application filed on             :   30.12.2015
PIO replied on                       :   11.02.2016
First Appeal filed on                :   16.02.2016
First Appellate Order on             :   11.04.2016
2nd Appeal/complaint received on     :   26.05.2016

Information sought

and background of the case:

The patient Smt. Kamla, a CGHS beneficiary (W/o of appellant) underwent bilateral knee replacement in CGHS approved hospital (Primus hospital) New Delhi in Sept. 2016. Since BSNL did not reimburse the entire medical expenses, the appellant sought information w.r.t. CGHS rules in this regard The appellant vide RTI application dated 30.12.2015 sought following information:-

1. It may not be right at all to allow (by BSNL) only one and half time of reduced package charge for bilateral knee replacement when the empanelled hospital (Primus) has charged differently. A clear cut direction may be issued so that the petitioner may approach to the appropriate authority either for recovery of deduction amount or refund amount in this case.

2. The Primus Hospital is empanelled in the category of NABH. The rate prescribed for total knee replacement for this hospital may be intimate.

3. On submission of complete medical claim, the time period within which such claims are settled be intimated.

The CPIO replied vide letter dated 11.02.2016 as under:-

1. - 2 As per CGHS guideline, if one or more minor procedure from part of a major treatment procedure, then package charge would be permissible for major procedure and only 50% of charge for minor procedure.

3. AS per CGHS guideline, the medical claims should be filed within 3 months of discharge from the hospital.

Dissatisfied with response received from CPIO, the appellant filed first appeal. The FAA upheld the CPIO's reply. Feeling aggrieved, the appellant approached the Commission.

Relevant facts emerging during hearing:

The Appellant is absent despite notice. The respondent from CGHS is present and heard. The appellant is an employee of BSNL. His wife underwent bilateral knee replacement surgery. The grievance of appellant is premised on the fact that the parent department of appellant (BSNL) reimbursed 100 % medical charges for one knee and the expenses incurred for other knee was reimbursed at the rate of 60%. In this factual backdrop, the appellant filed the present RTI application with CGHS to ascertain the position in this regard. The respondent form CGHS, Dr. Chatterjee in all fairness states that the relevant rule has been construed by BSNL in a narrow manner to the disadvantage of the appellant. He states that the rule is a general rule and does not lay special procedure for processing of claims of Total Knee Replacement Surgery. He states that BSNL ought to have allowed 100 % reimbursement of mediclaim of both knees.

Decision:

After hearing respondent and perusal of record, the Commission finds that requisite information has been furnished to the appellant. In light of the opinion expressed by respondent CGHS, the Commission hopes that BSNL shall reassess the admissibility of medical reimbursement claim of appellant.

The Appeal is disposed of.

(Yashovardhan Azad) Information Commissioner Page 2 of 3 Authenticated true copy. Additional copies of orders shall be supplied against application and payment of the charges prescribed under the Act to the CPIO of this Commission.

(R.P.Grover) Designated Officer Copy to:-