Summary of the Court's Order

Factual and Procedural Background

This document is an order disposing of procedural directions in a matter concerning Mediclaim Insurance Policies, including cashless Mediclaim Insurance Policies. The court granted leave to add the Insurance Information Bureau (IIB) as a party respondent and directed various filings and actions to obtain consolidated information about hospitals/nursing homes/clinics that accept cashless Mediclaim Insurance Policies.

Key procedural steps recorded in the order:

• Leave granted to add the Insurance Information Bureau as a party respondent; notice to the newly added party was made returnable on 12 February 2015.
• By an earlier order dated 20 November 2014, the General Insurance Council and the Association of Third Party Administrators (TPAs) were directed to place on record particulars about the number of hospitals/nursing homes/clinics which have accepted the cashless Mediclaim Insurance Policy.
• The petitioner placed on record a list of websites of 15 insurance companies that display particulars of hospitals/nursing homes/clinics accepting the cashless Mediclaim Insurance Policy.
• An affidavit dated 13 December 2014 of the Joint Director (Health), IRDA, describing steps taken by IRDA to ascertain compliance with the IRDA (Health Insurance) Regulations, 2013, was tendered and taken on record.
• The matter was stood over to 12 February 2015 for further action and response by the Insurance Information Bureau and for IRDA to seek instructions where necessary.

Legal Issues Presented

1. Whether the Insurance Information Bureau should be added as a party respondent and tasked to place on record findings of research regarding issues pertaining to Mediclaim Insurance Policies, including cashless policies.
2. How to obtain a consolidated and non-duplicative list of hospitals/nursing homes/clinics accepting cashless Mediclaim Insurance Policies (including whether a single agency should prepare such a list and assign unique identification numbers to facilities).
3. Whether IRDA should consider issuing instructions to Insurance Companies and TPAs to inform policyholders of reasons and remedies when claims are rejected or partially allowed, consistent with section 12(d)(ii) of the IRDA (Health Insurance) Regulations, 2013.

Arguments of the Parties

Petitioner's Position

• The petitioner placed on record a list of websites of 15 insurance companies that display particulars of hospitals/nursing homes/clinics accepting cashless Mediclaim Insurance Policies.
• The petitioner stated that the Insurance Information Bureau is an agency set up by the Insurance Regulatory and Development Authority (IRDA) and that therefore the information sought should be available through the Insurance Information Bureau.

General Insurance Council and Association of Third Party Administrators (TPAs)

• The learned counsel for the General Insurance Council and the Association of TPAs stated they were not in a position to indicate the exact number of hospitals/nursing homes/clinics accepting the cashless Mediclaim Insurance Policy because of overlapping entries in their data.

Insurance Regulatory and Development Authority (IRDA) / Mr. Chatterji

• Mr. Chatterji tendered an affidavit dated 13 December 2014 of the Joint Director (Health), IRDA, setting out the exercise undertaken by IRDA to ascertain compliance with the IRDA (Health Insurance) Regulations, 2013 by Insurance Companies and TPAs; the affidavit and annexures were taken on record.
• Mr. Chatterji, Senior Advocate for IRDA, prayed for time to seek instructions in the matter.

Table of Precedents Cited

No precedents were cited in the provided opinion.

Court's Reasoning and Analysis

The court's reasoning and directions, based solely on the contents of the order, proceeded as follows:

1. The court observed that the General Insurance Council and the Association of TPAs could not give an exact count of hospitals/nursing homes/clinics that accept cashless Mediclaim Insurance Policies due to overlap in the data reported to them.
2. To remedy the overlapping and lack of a consolidated list, the court considered it "worthwhile" to have a single agency prepare the list of hospitals/nursing homes/clinics which have accepted the cashless Mediclaim Insurance Policy and to assign a unique identification number to each facility so that relevant information can be collated uniquely.
3. Given that the petitioner represented the Insurance Information Bureau as an agency set up by IRDA and likely possessing the relevant information, the court granted leave to add the Insurance Information Bureau as a party respondent and directed that it place on record the findings of research made by it regarding issues pertaining to Mediclaim Insurance Policies, including cashless policies.
4. The court recorded that the petitioner had already placed on record a list of insurer websites (15 companies) showing particulars of participating hospitals/nursing homes/clinics, but the need for a consolidated, de-duplicated register remained.
5. The affidavit from the Joint Director (Health), IRDA, describing IRDA's compliance exercise under the IRDA (Health Insurance) Regulations, 2013, was accepted and taken on record, thereby giving the court a formal account of IRDA's steps to date.
6. Addressing consumer-information concerns, the court directed that IRDA shall consider issuing suitable instructions to Insurance Companies and TPAs that, when an insurance company rejects a claim or allows it only partially, the insurer/TPA shall inform the policyholder of the reasons for rejection or partial disallowance under section 12(d)(ii) of the IRDA (Health Insurance) Regulations, 2013, and of the remedies available to the policyholder.
7. Finally, the court granted time to IRDA's counsel to seek further instructions and stood the matter over to 12 February 2015 for the Insurance Information Bureau's response and for further proceedings.

Holding and Implications

Core Ruling: The court granted leave to add the Insurance Information Bureau as a party respondent and directed the Bureau to place on record findings of research regarding issues pertaining to Mediclaim Insurance Policies, including cashless Mediclaim Insurance Policies. The matter was stood over to 12 February 2015.

Direct consequences for parties:

• The Insurance Information Bureau was added as a respondent and required to respond to the court's suggestion to compile consolidated data and to place its research findings on record by the next date.
• The General Insurance Council and the Association of TPAs had previously been directed to place particulars on record; the court noted their inability to give an exact number due to overlapping data and recommended consolidation by a single agency with unique identifiers for facilities.
• IRDA's affidavit and annexures were taken on record; IRDA was directed to consider issuing instructions to insurers/TPAs to communicate reasons and remedies to policyholders when claims are rejected or partially allowed, pursuant to section 12(d)(ii) of the IRDA (Health Insurance) Regulations, 2013.
• The matter was adjourned to 12 February 2015 for the Insurance Information Bureau to respond and for IRDA counsel to obtain instructions.

No broader precedent was announced by this order; it sets procedural directions and records interim administrative steps to be taken by the Insurance Information Bureau and IRDA in relation to information consolidation and consumer communication under the stated regulation.