Central Information Commission
Tina Rijo vs The New India Assurance Company Ltd. on 6 June, 2024
केन्द्रीय सूचना आयोग
Central Information Commission
बाबा गंगनाथ मागग, मुननरका
Baba Gangnath Marg, Munirka
नई निल्ली, New Delhi - 110067
File No : CIC/NIACL/A/2023/617225
Tina Rijo .....अपीलकर्ाग /Appellant
VERSUS
बनाम
CPIO,
The New India Assurance Company Ltd.
Large Corporate & Brokers Office-II-990000,
New India Centre, Ground Floor, 17-A,
Cooperage Road, Mumbai-400039. .....प्रनर्वािीगण /Respondent
Date of Hearing : 03.06.2024
Date of Decision : 03.06.2024
INFORMATION COMMISSIONER : Vinod Kumar Tiwari
Relevant facts emerging from appeal:
RTI application filed on : 08.02.2023
CPIO replied on : 14.02.2023
First appeal filed on : 15.02.2023
First Appellate Authority's order : Not on record
2nd Appeal/Complaint dated : Nil
Information sought:
The Appellant filed an RTI application dated 08.02.2023 seeking the following information:Page 1 of 5
"I applied for an Insurance claim through MdiIndia TPA. My insurance company was The New India Assurance however the TPA had not shown any interest in solving nor my insurance company has shown any interest in replying to my request regarding my insurance claim. I am pregnant and my hospital has told me to get admitted for the initial 3 months due to some complications I informed the TPA regarding the same. I started rigorously following up with them regarding my claim and they rejected my claim on the grounds of the treatment given to the patient does not support the need for hospitalization and is not succeeded by an active line of treatment Neither the grievances committed replied to my emails in spite of regular follow up."
The CPIO furnished a reply to the Appellant on 14.02.2023 stating as under:
"This has reference to your application addressed to the Public Information Officer, The New India Assurance Co. Ltd, Mumbai LCBO II seeking information under RTI Act, 2005. In this regard, we have gone through the captioned claim file and hereby provide reply for the information sought-
1. This is reference to the RTI application received to us. We have verified with the TPA that the said claim is neither lodged with our office nor with TPA."
Being dissatisfied, the appellant filed a First Appeal dated 15.02.2023. The FAA order is not on record.
Feeling aggrieved and dissatisfied, appellant approached the Commission with the instant Second Appeal on the following grounds -
"I applied for an Insurance claim through MdiIndia TPA. My insurance company was The New India Assurance however the TPA had not shown any interest in solving nor my insurance company has shown any interest in replying to my request regarding my insurance claim. I am pregnant and my hospital has told me to get admitted for the initial 3 months due to some complications I informed the TPA regarding the same. I started rigorously following up with them regarding my claim and they rejected my claim on the grounds of the treatment given to the patient does not Page 2 of 5 support the need for hospitalization and is not succeeded by an active line of treatment Neither the grievances committed replied to my emails inspite of regular followups.
Attached the claim form and discharge summary The RTI reply received on 14/02/2023 for the RTI filed is false and misleading.
Request you to kindly consider my case."
Relevant Facts emerged during Hearing:
The following were present:-
Appellant: Not present.
Respondent: Ms. Shobha Crasto, Dy. Director-cum-CPIO present through video-conference.
Respondent submitted that as per the claim documents filed by the Appellant it was observed that the treatment taken by her does not support the need for hospitalization and was not succeeded by any active line of treatment, therefore, her claim was repudiated because the subject policy do not covers pre-natal and post-natal expenses. She further apprised the Commission that Group Insurance Policy has been purchased by TISS who is the employer of the Appellant and also the Insured with the Respondent Public Authority, therefore, it is the duty of the TISS to inform the T & C including the nature of coverage policy given to its employees.
Decision:
The Commission after adverting to the facts and circumstances of the case, perusal of records observes that as far as RTI application is concerned appropriate response has been furnished by the Respondent against the grievance of the Appellant regarding non-receipt of medical insurance claim which is outside the scope of RTI Act.
Nonetheless, the Commission is unhappy with the approach followed by the TISS and Respondent Public Authority in denying the genuine claim of the Appellant firstly by defining pregnancy as a disease which is actually a Page 3 of 5 biological process and secondly, by denying the claim on the ground that pre- natal hospitalization not covered ignoring the fact that no prudent person would like to be hospitalized merely for the sake of getting reimbursement. Such illogical unfair practices should be avoided by the Respondent in the fair governance.
Further, looking into the gravity of issue flagged by the Appellant, TISS in terms of Section 25(5) of the RTI Act is advised to procure an insurance policy in favour of their employees which would cover pregnancy of their employees in the reproductive age.
This bench has dealt with multiple cases where policy holders (buyers of Group Insurance Policy) neither disclose to the employees anything about the Group Insurance Policy nor to the nominees of the employees that he/she was made a nominee by the employee. Thus, on filing of medi-claim by the ultimate beneficiary they had no means to know whether anyone was made a nominee. Under such circumstances. Gap in such a vital information affords opportunities for potential scams happening and going unnoticed. One such suspected instance was brought to the notice of the Commission in the case of Alok Kumar v. LIC bearing File No. CIC/LIC/A/2023/605048 & Others decided on 29.04.2024 and the other one being the case titled Geroge Thomas v. LIC bearing File No. CIC/LICOI/A/2023/151212 DECIDED ON 29.01.2024 and advisory to the same public authority was issued to strengthen the information dissemination mechanism. Same advisory is reiterated in this case also.
In view of the above, the Commission directs the Respondent to serve a copy of this order to the concerned competent authority of TISS to take necessary action.
No further relief can be granted in the matter.
The appeal is disposed of accordingly.
Vinod Kumar Tiwari (विनोद कुमार वििारी) Information Commissioner (सूचना आयुक्त) Page 4 of 5 Authenticated true copy (अनिप्रमानणर् सत्यानपर् प्रनर्) (S. Anantharaman) Dy. Registrar 011- 26181927 Date Copy To:
The FAA, The New India Assurance Company Ltd. Large Corporate & Brokers Office-II-990000, New India Centre, Ground Floor, 17-A, Cooperage Road, Mumbai-400039.Page 5 of 5
Recomendation(s) to PA under section 25(5) of the RTI Act, 2005:-
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