Central Information Commission
S Ramalingam vs The New India Assurance Company Ltd. on 28 November, 2024
के ीय सूचना आयोग
Central Information Commission
बाबा गंगनाथ माग, मुिनरका
Baba Gangnath Marg, Munirka
नई िद ी, New Delhi - 110067
File No: CIC/NIACL/A/2023/136650
S Ramalingam .....अपीलकता/Appellant
VERSUS
बनाम
CPIO,
The New India Assurance Company
Limited Chennai Regional Office - 710000,
Dewa Towers, 3rd Floor, 770A Anna Salai,
Chennai - 600 002 .... ितवादीगण /Respondent
Date of Hearing : 25.11.2024
Date of Decision : 27.11.2024
INFORMATION COMMISSIONER : Vinod Kumar Tiwari
Relevant facts emerging from appeal:
RTI application filed on : 12.06.2023
CPIO replied on : 27.06.2023
First appeal filed on : 06.07.2023
First Appellate Authority's order : 14.07.2023
2nd Appeal/Complaint dated : 31.08.2023
Information sought:
The Appellant filed an (offline) RTI application dated 12.06.2023 seeking the following information:Page 1 of 6
"Ref: My Health Policy No. 71260034219500001227
2. From Raksha TPA repudiation email non pay per claim 1572602290025574 dt 10.02.23.
Kindly furnish the following details:
A) Terms & Conditions or clauses under which my claim was repudiated. B) The Date of effect of such clause applicable to my health policy. C) An extract of such Terms & Conditions or Clause D) Attested copies of entire correspondence or file available for such repudiation for my claim."
The CPIO furnished a reply to the Appellant on 27.06.2023 stating as under:
"A) Terms & Conditions or clauses under which my claim was repudiated.
REPLY: The claim was reopened and settled for the balance amount of Rs.12,882/- and we are sharing payment particulars:
UTR NO AXISCN0221878636 DT.14.3.23 FOR RS.6,061/- AND UTR NO. AXISCN0246578747 DT.04.05.23 FOR R5.6,821/- HENCE NO REPUDIATION AND TERMS & CONDITIONS OR CLAUSES UNDER WHICH CLAIM WAS REPUDIATED IS NOT PROVIDED. B) The Date of effect of such clause applicable to my health policy.
REPLY: NEW INDIA MEDICLAIM POLICY CLAUSE IS APPLICABLE FROM THE INCEPTION DATE OF YOUR NEW INDIA MEDICLAIM POLICY. C) An extract of such Terms & Conditions or Clause REPLY : NEW INDIA MEDICLAIM POLICY CLAUSE ATTACHED. D) Attested copies of entire correspondence or file available for such repudiation for my claim.
REPLY: THE CLAIM HAS BEEN REOPENED AND SETTLED. HENCE ATTESTED COPIES OF ENTIRE CORRESPONDENCE OR FILE AVAILABLE FOR SUCH REPUDIATION OF YOUR CLAIM IS NOT PROVIDED."
Being dissatisfied, the appellant filed a First Appeal dated 06.07.2023. The FAA vide its order dated 14.07.2023, held as under.
"On receipt of an Appeal, the CPIO, CHENNAI RO was advised to re- examine the RTI application dated 12.6.2023 with regard to Items A & D of the Information sought and furnish revised reply within the ambit of the RTI Act.
Revised reply by the CPIO, CHENNAI RO. is reproduced as under & copies attached:
A) Terms & Conditions or clauses under which my claim was repudiated.Page 2 of 6
REPLY: ORIGINALLY REPUDIATED AS PER CLAUSE NO.5.9 MULTIPLE POLICIES, OF NEW INDIA MEDICLAIM POLICY CLAUSE. HOWEVER, SUBSEQUENTLY RE- OPENED AND PAID.
D) Attested copies of entire correspondence or file available for such repudiation, for my claim.
As regards information under ITEM B & C sought by the Appellant, CPIO's reply provided at the application Stage for ITEM B & C is upheld. Information 'as held' & within the definition of section 2(f) of the RTI Act has been furnished & CPIO have no more obligation to discharge under RTI Act."
Feeling aggrieved and dissatisfied, appellant approached the Commission with the instant Second Appeal.
Relevant Facts emerged during Hearing:
The following were present:-
Appellant: Present through video conference.
Respondent: Shri M. Bhaskaran, CPIO, appeared through video conference.
The appellant inter alia submitted that he has not received the proper and satisfactory information on point Nos. (A) and (D) of the RTI application. He pleaded that copy of terms & conditions or clauses under which his claim was repudiated and copies of entire correspondence or file available for such repudiation, was not provided by the respondent till the date of hearing.
The respondent while defending their case inter alia submitted that they had filed a detailed written submissions dated 14.11.2024 stating complete facts of the case, a copy of the same is marked to the appellant and requested the Commission to place it on record. The relevant paras of the written submission are reproduced as under:
"The background of the application/appeal appears that the applicant has a grievance relating to claim under Mediclaim Insurance policy no.71260034219500001227 issued to him by Chennai Regional Office.
The applicant, vide his application dt. 12.6.2023 sought various information related to the said claim through 4 points (A to D) from Chennai Regional Office.Page 3 of 6
The CPIO, Chennai Regional Office has responded to the RTI application vide O/RTI/785R DT. 27.06.2023 (ANNEXURE 'A') giving point wise reply (points A to D) along with extract terms and conditions or clause in respect of point no. C. Not satisfied with the reply, the applicant has submitted First Appeal dt.06.07.2023.
The First Appeal was decided vide FAA Appeal Order no. CHNRO/RTI/29A/R dt. 14.07.2023 (ANNEDURE 'B') upholding the information furnished by the CPIO under ITEM B & C. The insured is covered under the Mediclaim Policy of The New India Assurance Co. Ltd since 09.03.2007. The subject policy has been issued for a sum insured of Rs.4,00,000/- each for Self and Spouse. He is also covered under the Tamil Nadu Govt. Health Insurance Scheme for a sum insured of Rs.5,00,000/- and made the initial claim with United India Insurance Company for an amount of Rs.2,38,281/- and against this they have settled Rs. 1,73,073/-.
The applicant has approached our TPA M/s Raksha Health Insurance TPA for the uncovered amount of Rs.65,208/-. TPA in consultation with us as per clause 5.9 relating to multiple policies and after deducting the amount settled by the other insurer, they have arrived at an amount of Rs. 12,882/- and paid Rs.6,061/- vide UTR no.AXISCNO0221878636 DT.14.3.23 after adjusting Rs.6821/- towards 10% Hospital Discount on investigation charges. Based on his representation this was also paid to him vide UTR no.AXISCN0246578747 DT.04.05.23.
Aggrieved even after this, the applicant approached Insurance Ombudsman, Chennai on 26.05.2023. It was amply explained to the Ombudsman that the expenses disallowed are related to non-payables and non- medical items under both Insurers' policies.
Submission from CPIO order dt.05.06.2023 (ANNEXURE 'C') after hearing both the parties has directed us to settle an amount of Rs.2,850/-being the Emergency Room Page 4 of 6 Assessment Charges which has been paid vide UTR AXISCN0280902816 dt.30.06.2023 which has been acknowledged by the applicant in his Second Appeal to the Hon'ble Information Commissioner.
Hence, we conclude that the subject claim has not been repudiated by us, but processed on merits and paid all allowable items after deducting the other insurer's settlement as per the terms, and conditions of the policy.
Sir, in light of the above clarifications, it may be noted that so far as all the desired disclosable information within the purview of the RTI Act has been furnished to the appellant. We feel no further RTI indulgence in the matter.
In view of the above, we dutifully pray that the Hon'ble Commissioner dismiss the appeal and uphold the decision of CPIO."
As regards the repudiation of the claim, the respondent submitted that the appellant's claim was not repudiated and instead his claim was settled as per the terms and conditions of the policy.
Decision:
The Commission after adverting to the facts and circumstances of the case, hearing both the parties and perusal of the records, noted that point-wise information as available with the respondent has been provided to the appellant vide letters dated 27.06.2023 and 14.07.2023. The respondent has filed a detailed written submission dated 14.11.2024 stating complete facts of the case, a copy of the same is served to the appellant.
The appellant's main contention was that copy of terms & conditions or clauses under which his claim was repudiated and copies of entire correspondence or file available for such repudiation as sought on point Nos. (A) and (D) of the RTI application, was not provided by the respondent. In this regard, the respondent submitted that the appellant's claim was not repudiated because his claim was settled as per the terms and conditions of the policy which was available with them. Thus, it is not a case of repudiation of the insurance claim, therefore, the contention of the appellant is not sustainable in the eyes of law.Page 5 of 6
In view of the above, the Commission finds that reply given by the respondent is in consonance with the provisions of the RTI Act and interference of the Commission is not warranted in the matter.
The appeal is disposed of accordingly.
Vinod Kumar Tiwari (िवनोद कुमार ितवारी) Information Commissioner (सूचना आयु ) Authenticated true copy (अिभ मािणत स!ािपत ित) (S. Anantharaman) Dy. Registrar 011- 26181927 Date Copy To:
The FAA DGM, The New India Assurance Company Limited Chennai Regional Office - 710000, Dewa Towers, 3rd Floor, 770A Anna Salai, Chennai - 600 002 Page 6 of 6 Recomendation(s) to PA under section 25(5) of the RTI Act, 2005:-
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