Breakdown of the medical expenses incurred during the cataract surgery

The reimbursement of appellant’s cataract surgery raised with Insurers was restricted to Rs. 30,000 by TPA. The appellant submitted that he is entitled to Rs 50,000/- i.e. 10% of sum insured but the insurers restricted 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. The CIC observed 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. Further, 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. The CIC directed the PIO 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, free of cost, to the appellant.

Comments This order would pave the way for the transparency in the processing of the insurance claims. Hopefully, the insurers would provide the detailed breakdown to the

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

Dr Anuradha Verma (dranuradhaverma@yahoo.co.in) is a RTI Consultant currently working with IIM Visakhapatnam. She has co-authored the books, RTI Right to Information - Law and Practice and PIO’s Guide to RTI. She offers consultancy on RTI matters and Third party audit. Her other articles can be read at the website of RTI Foundation of India at the link www.rtifoundationofindia.com