Can’t deny medical reimbursement to employees treated outside empanelled hospitals: SC

Feb. 10: In what seems to be a big relief for Central government employees, the Supreme Court has said that employees can’t be denied health insurance benefits (Mediclaim) just because they chose a private hospital instead of the government hospital listed with the CHGS (Central Government Health Scheme) panel.

A Bench comprising Justices R K Agarwal and Ashok Bhushan said that, “Reimbursement cannot be denied either during service or after retirement if the employee does not seek treatment from a hospital which is not in the government panel or in the list of the Central Government Health Scheme (CGHS) empanelled hospitals.”  The order was passed on a petition filed by a retired CG employee who had taken treatment from two private hospitals and sought reimbursement of medical bills.

The apex court further added, “The real test must be the factum of treatment. Before any medical claim is honoured, 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 went on to add that the government will only have to verify that the claim being made by an employee or a pensioner is in the record of a certified doctor or hospital or not. The apex court said that the government can also verify if the employee or pensioner concerned has actually taken treatment or not. Based on these facts, an employee or a pensioner can be denied or granted Mediclaim, it said.

It also directed the setting up of “Committee for grievance redressal of the retired pensioners consisting of Special Directorate General, Directorate General, 2 (two) Additional Directors and a specialist in the field which shall ensure timely and hassle-free disposal of the claims within a period of seven days.”