Kumari Priya And ANR v. Employees State Insurance Corporation & ORS

Appl.Side-5 $~ * IN THE HIGH COURT OF DELHI AT NEW DELHI + KUMARI PRIYA AND ANR ..... Petitioners Through Mr. Ashok Aggarwal, Advocate versus EMPLOYEES STATE INSURANCE CORPORATION & ORS ..... Respondents Through Ms. Shyel Trehan, Amicus Curiae with Ms. Sonali Malik, Advocate.

Ms. Shiva Lakshmi, CGSC with Mr. Siddharth Singh, Mr.

Ruchir R. Rai, Mr. Sanjeev Uniyal with Mr. Dhawal Uniyal, 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. Anand Verma and Mr.

Shwetank Singh and Mr.

Tanveer Oberoi Advocates for AIIMS.

Mr. Rajshekhar Rao with Mr.

Kotla Harshvardhan and Ms.

Mansi Sood, Advocate for Sanofi Genzyme.

% Date of Decision: 16th April, 2019

CORAM:

HON'BLE MR. JUSTICE MANMOHAN

J U D G M E N T

MANMOHAN, J: (Oral) 1.

Present writ petition has been filed by Kumari Priya. As the petitioner-patient is suffering from a rare genetic disorder named Gaucher disease Type-1, 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. She has also challenged Clause 5.3 of the ESIC Decisions on Medical Services-July, 2014.

3.

During the pendency of the present writ petition, the impugned Clause 5.1 has been amended by way of a Circular dated 07th 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 Priya Father's Name Mr.Raj Bali Age 15 years Gender Female Insurance No.

6910928780 Diagnosis Gaucher's Disease The above case was discussed in the meeting and all the documents were reviewed. This child has been diagnosed as Gaucher's disease Type-I in November, 2015 based on clinical examination, investigations and as per prescription from All India Institute of Medical Sciences (AIIMS), Deptt. of Paediatrics, New Delhi and the treatment was started in July, 2016.

The prescribed drug (Cerezyme) is being procured by the ESICH, Manesar, Haryana and is being administered at Deptt. of Pediatrics, ESIC Hospital, Manesar, Haryana.. 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."

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