Sangeetha And Anr vs Employees State Insurance ...
2019 Latest Caselaw 2081 Del

Appl.Side-6
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*    IN THE HIGH COURT OF DELHI AT NEW DELHI

+      W.P.(C) 8474/2017

       SANGEETHA AND ANR                    ..... Petitioners
                   Through       Mr. Ashok Aggarwal, Advocate

                       versus

       EMPLOYEES STATE INSURANCE
       CORPORATION AND ORS               ..... Respondents
                    Through  Ms. Shyel Trehan, Amicus
                             Curiae with Ms. Sonali Malik,
                             Advocate.
                             Ms. Shiva Lakshmi, CGSC and
                             Mr. Bhagwan Swarup Shukla,
                             CGSC with Mr. Mukesh Kumar
                             Pandey, Advocate for UOI.
                             Mr. Yakesh Anand with Mr.
                             Nimit Mathur, Advocates and
                             Dr. Naresh Arora, AD (D) and
                             Mr. Dhruv Prasad UDC for
                             ESIC.
                             Mr. Ramesh Singh, Standing
                             Counsel (Civil) with Mr.
                             Chirayu Jain, Advocate for
                             GNCTD.
                             Mr. Tanveer Oberoi, Advocate
                             for AIIMS.
                             Mr. Rajshekhar Rao with Mr.
                             Kotla Harshvardhan and Ms.
                             Mansi Sood, Advocate for
                             Sanofi Genzyme.
                             Mr. Sumit Rajput, Advocate for
                             respondent.



W.P.(C) 8474/2017                                Page 1 of 4
 %                                 Date of Decision: 16th April, 2019

CORAM:
HON'BLE MR. JUSTICE MANMOHAN

                            JUDGMENT

MANMOHAN, J: (Oral)

1. Present writ petition has been filed by Ms. Sangeetha. As the petitioner-patient is suffering from a rare genetic disorder named Gaucher disease, she seeks extension of medical cover for life saving Enzyme Replacement Therapy on the ground that her father is insured with Employees State Insurance Corporation (for short 'ESIC').

2. In the present writ petition, it has been averred that ESIC had denied medical treatment to the petitioner citing Clause 5.1 of the ESIC Decisions on Medical Services-July, 2014 inasmuch as it imposed a ceiling limit of Rs.10 lacs per beneficiary per year.

3. During the pendency of the present writ petition, the impugned Clause 5.1 has been amended by way of a Circular dated 07 th November, 2016 wherein it has been stipulated that for all the cases where expenditure incurred/to be incurred is more than Rs.10 lacs per beneficiary, the same shall be examined on case to case basis by a Committee constituted by ESIC Headquarter office and a decision with the approval of Chairman ESI Corporation shall be taken.

4. Thereafter, the petitioner's case was placed before the said Committee. The said Committee found the petitioner eligible for treatment. The Committee's report dated 12th July, 2018 is reproduced hereinbelow:-

                "Name of Patient                Miss Sangeetha
               Father's Name                   Mr. Nagarajan
               Age                             21 years
               Gender                          Female
               Insurance No.                   5611141385
               Diagnosis                       Gaucher Disease

The above patient was admitted in Department of medicine, ESIC PGIMSR, K.K. Nagar, Chennai. The discharge summary dated 03.04.2017 mentions that the patient was provisionally diagnosed as Gaucher's disease based on clinical examination & Bone marrow aspiration & Biopsy.

She was transferred to Madras Medical College for further evaluation & management. However, no papers of Madras Medical College are enclosed. There are 2 blood reports (one from Sandor Life Sciences Pvt. Ltd., Hyderabad and one from Lister Metropolis, Chennai) both are showing deficiency of B glycosidase enzyme suggestive of Gaucher's disease.

The patient meets the eligibility criteria for super specialty treatment as per ESI norms.

As per email received from RD, Tamilnadu, her treatment commenced based on the Letter No.:U- 16/30/632/2017 Pro.Cell (SST)/ERT Court Cases/P-III 1992 dt: 01/02/2018 from DMC, SST, ESIC Headquarters. The Purchase Orders are being placed to M/s. Sandor Medicals. So far 3 Purchase Order (14 vials each) for procurement and supply of the drug - Cerezyme has been placed. The drugs are being delivered at ESIS Hospital, Salem and the same is being administered there. The Dosage of the drug is calculated based on the weight of the patient.

The committee recommends that all the investigation reports and treatment details may be called for further examination and recommendation."

5. Learned counsel for the petitioners states that the petitioners are receiving medical treatment in accordance with the aforesaid decision.

6. The respondent-ESIC is directed to comply with the aforesaid recommendation of the Committee and grant medical treatment to the petitioner.

7. With the aforesaid direction, the present writ petition stands disposed of.

MANMOHAN, J APRIL 16, 2019 js