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V. BENEFITS




55. Review of decisions by Medical Board or Medical Appeal Tribunal
(1) Any decision under this Act of a medical board or a medical appeal tribunal may be reviewed at any time by the medical board or the medical appeal tribunal as the case may be if it is satisfied by fresh evidence that the decision was given in consequence of the non-disclosure or mis-representation by the employee or any other person of a material fact (whether the non-disclosure or misrepresentation was or was no fraudulent).
(2) Any assessment of the extent of the disablement resulting from the relevant employment injury may also be reviewed by a medical board if it is satisfied that since the making of the assessment there has been a substantial and unforeseen aggravation of the results of the relevant injury :
Provided that an assessment shall not be reviewed under this sub-section unless the medical board is of opinion that having regard to the period taken into account by the assessment and the probable duration of the aggravation aforesaid substantial injustice will be done by not reviewing it.
(3) Except with the leave of a medical appeal tribunal an assessment shall not be reviewed under sub-section (2) on any application made less than five years or in the case of a provisional assessment six months from the date thereof and on such a review the period to be taken into account by any revised assessment shall not include any period before the date of the application.

(4) Subject to the foregoing provisions of this section a medical board may deal with a case of review in any manner in which it could deal with it on an original reference to it and in particular may make a provisional assessment notwithstanding that the assessment under review was final; and the provisions of section 54A shall apply to an application for review under this section and to a decision of a medical board in connection with such application as they apply to as a case for disablement benefit under that section and to a decision of the medical board in connection with such case.



55A. Review of dependants' benefit
(1) Any decision awarding dependants' benefit under this Act may be reviewed at any time by the Corporation if it is satisfied by fresh evidence that the decision was given in consequence of non-disclosure or misrepresentation by the claimant or any other person of a material fact (whether the non-disclosure or misrepresentation was or was not fraudulent) or that the decision is no longer in accordance with this Act due to any birth or death or due to the marriage re-marriage or cesser of infirmity of or attainment of the age of eighteen years by a claimant.
(2) Subject to the provisions of this Act the Corporation may on such review as aforesaid direct that the dependants' benefit be continued increased reduced or discontinued.

56. Medical benefit
(1) An insured person or (where such medical benefit is extended to his family) a member of his family whose condition requires medical treatment and attendance shall be entitled to receive medical benefit.
(2) Such medical benefit may be given either in the form of out-patient treatment and attendance in a hospital or dispensary clinic or other institution or by visits to the home of the insured person or treatment as in-patient in a hospital or other institution.
(3) A person shall be entitled to medical benefit during any period for which contributions are payable in respect of him or in which he is qualified to claim sickness benefit or maternity benefit or is in receipt of such disablement benefit as does not disentitle him to medical benefit under the regulations:
Provided that a person in respect of whom contribution ceases to be payable under this Act may be allowance medical benefit for such period and of such nature as may be provided under the regulations:
Provided further that an insured person who ceases to be in insurable employment on account of permanent disablement shall continue subject to payment of contribution and such other conditions as may be prescribed by the Central Government to receive medical benefit till the date on which he would have vacated the employment on attaining the age of superannuation had he not sustained such permanent disablement:

Provided also that an insured person who has attained the age of superannuation and his spouse shall be eligible to receive medical benefit subject to payment of contribution and such other conditions as may be prescribed by the Central Government.


Explanation: In this section superannuation in relation to an insured person means the attainment by that person of such age as is fixed in the contract or conditions of service as the age on the attainment of which he shall vacate the insurable employment or the age of sixty years where no such age is fixed and the person is no more in the insurable employment.

57. Scale of medical benefit
(1) An insured person and (where such medical benefit is extended to his family) his family shall be entitled to receive medical benefit only of such kind and on such scale as may be provided by the State Government or by the Corporation and an insured person or where such medical benefit is extended to his family his family shall not have a right to claim any medical treatment except such as is provided by the dispensary hospital clinic or other institution to which he or his family is allotted or as may be provided by the regulations.
(2) Nothing in this Act shall entitle an insured person and (where such medical benefit is extended to his family) his family to claim re-imbursement from the Corporation of any expenses incurred in respect of any medical treatment except as may be provided by the regulations.

58. Provision of medical treatment by State Government
(1)  The State Government shall provide for insured persons and (where such benefit is extended to their families) their families in the State reasonable medical surgical and obstetric treatment:
Provided that the State Government may with the approval of the Corporation arrange for medical treatment at clinics of medical practitioners on such scale and subject to such terms and conditions as may be agreed upon.
(2) Where the incidence of sickness benefit payment to insured persons in any State is found to exceed the all-India average the amount of such excess shall be shared between the Corporation and the State Government in such proportion as may be fixed by agreement between them:
Provided that the Corporation may in any case waive the recovery of the whole of any part of the share which is to be borne by the State Government.

(3) The Corporation may enter into an agreement with a State Government in regard to the nature and scale of the medical treatment that should be provided to insured persons and (where such medical benefit is extended to the families) their families (including provision of buildings equipment medicines and staff) and for the sharing of the cost thereof and of any excess in the incidence of sickness benefit to insured persons between the Corporation and the State Government.


(4) In default of agreement between the Corporation and any State Government as aforesaid the nature and extent of the medical treatment to be provided by the State Government and the proportion in which the cost thereof and of the excess in the incidence of sickness benefit shall be shared between the Corporation and that government shall be determined by an arbitrator (who shall be or shall have been a Judge of the High Court of a State appointed by the Chief Justice of India and the award of the arbitrator shall be binding on the Corporation and the State Government.

59. Establishment and maintenance of hospitals etc. by Corporation
(1) The Corporation may with the approval of the State Government establish and maintain in a State such hospitals dispensaries and other medical and surgical services as it may think fit for the benefit of insured persons and (where such medical benefit is extended to their families) their families.
(2) The Corporation may enter into agreement with any local authority private body or individual in regard to the provision of medical treatment and attendance for insured persons and (where such medical benefit is extended to their families) their families in any area and sharing the cost thereof.


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