Sangeetha And ANR v. Employees State Insurance Corporation And ORS

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

% 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 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 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 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.:U16/30/632/2017 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