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In the matter of Marimuthu v. Government of Tamil Nadu & Ors a single judge bench of the Madras HC observed that “medical reimbursement claims of the employees and pensioners cannot be easily brushed aside by the state projecting technical reasons”. The above observation of the HC came in a writ petition filed by various government employees and Pensioners who are entitled for medical reimbursement under the State’s Scheme but their claims are rejected by the State on flimsy and technical grounds.
The petitioners contended before the court that the state government had compelled employee or pensioner of the State Government for compulsory and continuous contribution towards the Health Insurance Scheme. However after this contribution the state is denying its duty and responsibility of reimbursing the claims by rejecting the cases on merely technical grounds.
Under the Tamil Nadu government’s Heath Insurance Scheme every employee of the State Government and Public sector undertakings would compulsorily pay premium of Rs.150/- per month to the State Government and the said amount would be deducted from their salary. In turn, the State Government entered into an agreement with United India Insurance Company Ltd., Chennai and accordingly, the annual premium of Rs.1,860 would be paid by the State Government to the Insurance company as a yearly premium for the employee, under which the employee, as well as his family, would be covered under the Insurance scheme. The scheme would be implemented as a cashless model for the approved treatments/surgeries in the hospitals and their eligible family members would be covered under the scheme and shall avail financial assistance. However, the HC bench found out the fact that the District Level Empowered Committee have rejected the claims of petitioners for reimbursement in one line without giving any plausible or acceptable reason like the treatment taken in non network hospital or for the non-listed disease.
The HC bench in its decision remarked that even if it is assumed that the treatment has been taken in non-network hospital, it is the duty of the District Level Empowered Committee or at least at the State Level high power committee to go in to the claim and to see whether the treatment had been taken in a non-network hospital for any plausible reason like emergency or immediate non-availability of the network hospital in the locality. Following the judgment in Shiva Kant Jha v. Union of India HC bench observed that the real test of the claim must be the factum of treatment. Before any medical claim is accepted, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors / hospitals concerned. Once it is established, the claim cannot be denied on technical grounds.
The bench held that the Right to Health forms a part of Right to Life which is enshrined under Article 21 of the Constitution and thereby the state should assure protection cover as far as good health of its subjects goes. Therefore the obligation of the State Government and their duty towards achieving this goal cannot be abdicated on any flimsy or technical reasons. Court said that the State Government's obligation cannot be easily given up or washed away in the manner it has been done in these cases and thereby, none of the impugned orders passed in the batch of cases are sustainable.
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