Master Vishal Kumar (Minor) And ... vs Employees State Insurance ...
2019 Latest Caselaw 2082 Del

Appl.Side-3
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*    IN THE HIGH COURT OF DELHI AT NEW DELHI

+      W.P.(C) 2609/2016 & CM APPL. 11034/2016

       MASTER VISHAL KUMAR
       (MINOR) 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. Vivek Goyal, CGSC with
                             Mr. Pawan Pathak, Mr.
                             Siddharth Singh, Mr. Ruchir R.
                             Rai and Mr. Santosh Kumar
                             Pandey, Advocates 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.

%                               Date of Decision: 16th April, 2019


W.P.(C) 2609/2016                                        Page 1 of 4
 CORAM:
HON'BLE MR. JUSTICE MANMOHAN

                            JUDGMENT

MANMOHAN, J: (Oral)

1. Present writ petition has been filed by Master Vishal Kumar. As the petitioner-patient is suffering from a rare genetic disorder named MPS Type-I, he seeks extension of medical cover for life saving Enzyme Replacement Therapy on the ground that his 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                 Master Vishal Kumar
               Father's Name                    Mr. Ashok Singh
               Age                              09 years



                Gender                          Male
               Insurance No.                   2206567936
               Diagnosis                       Hurler's Syndrome

The above case has been diagnosed as a case of Mucopolysaccharidosis MPS Type-I (Hurler Syndrome) based on Low-aInduronidase activity at AIIMS, New Delhi.

The patient has been prescribed Injection Laronidase (Aldurazime 2.9 mg) every week by Deptt. of Paediatrics at All India Institute of Medical Sciences, New Delhi. Till now the transfusions are being given in department of Pediatrics, AIIMS, new Delhi and the medicine was being procured from ESIC Hospital, Basaidarapur, However, in future the same will be given at ESIC Hospital Basaidarapur, New Delhi.

As per the published literature the Enzyme Replacement Therapy (ERT) is beneficial in these cases to ameliorate their symptoms and signs. Such patients may lead near normal life if proper treatment is started at any early age and continued uninterruptedly. Hence, the committee recommends that the treatment of this patient to be continued as before.

The Committee further recommends that a progress report be maintained at level of treating hospital/RD to assess the response to Enzyme Replacement Therapy (ERT). For this a detailed Performa & a diary card have been framed by the department of Pediatrics, ESIC PGIMSR, Basaidarapur, New Delhi (proforma enclosed). The same may be asked by the ESIC Hqrs. Office at any time.

As per documents, this patient is eligible for SST treatment as per ESIC eligibility criteria vide circulars dated 07.11.2016 & 15.12.2016. Verification of the IP as per the HCT proforma has been done (attached)."

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 and application stand disposed of.

MANMOHAN, J APRIL 16, 2019 js