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Judgment
The petitioner herein, who is serving as Head Constable in the Highway-Patrol Wing of the Paramathi-Vellore Police Station, has filed this Writ
Petition seeking issuance of a direction to Respondent Nos.2 and 3/Insurance Company and Agency to issue the Authorization Letter in favour of
the 4th Respondent/Hospital, enabling the latter to proceed with the treatment to be given to the petitioner, who is a chronic heart patient already
underwent Bypass Surgery and now suffering from coronary heart disease called Ischemic Cardiomyopathy.
The Government of Tamil Nadu, in an endeavor to provide health care assistance on a ''cashless model'' to its employees in the Government
Departments, Public Sector Undertakings, Statutory Board, Local Bodies and State Government Universities, etc. and also the eligible family
members of those employees, implemented the New Health Insurance Scheme 2016 (in short, NHIS-2016) through G.O.Ms.No.202, Finance
(Salaries) Department, dated 30.06.2016, providing medical assistance upto the limit of Rs.7.50 lakhs for diseases listed out in Annexure II-A
thereof, in a block of four years under the Scheme.
Learned counsel for the petitioner, after referring to the features of the NHIS-2016, would submit that the petitioner, who had joined the Tamil
Nadu Police Service in the year 1993 as Grade-II Constable and later promoted as Grade-I Constable and presently serving as Head Constable
in the Highway- Patrol Wing attached to Paramathi-Vellore Police Station, has been suffering from heart ailments for the past 15 years. He was
performed Bypass Surgery at R-4/Madras Medical Mission in the year 2003, for which, a sum of Rs.2,00,000/- was spent and the same was paid
by the Government of Tamil Nadu directly. The petitioner, who is presently 42 years old, even after undergoing the bypass surgery, is not
completely cured of the heart disease since he is still suffering a lot of pain and undergoing mental agony due to prolonged illness. While so, during
2016, his heart ailment aggravated further, whereupon, he approached the 4th respondent/Specialized Hospital for Cardio-vascular Diseases. He
was diagnosed to have a peculiar/uncommon heart ailment, because of which, he has heart beat at the rate of 30 per minute as against the normal
rate of 80 per minute, thus, his life is in imminent danger. It is only to treat such uncommon and rare heart disease, the 4th respondent/Hospital
advised the petitioner to immediately undergo a Coronary Angiography Test, Radio Frequency Ablation Using Ensite and Permanent Pacemaker
Implantation (AICD) and the treatment expense was estimated as Rs.6,60,550/-.
After so submitting, learned counsel for the petitioner would contend that the petitioner, from whose salary a sum of Rs.180/- per month is being
deducted towards the premium payable under the NHIS-2016, approached the 4th respondent/Hospital to provide him cashless treatment under
the NHIS-16. Since pre-authorization is required to be obtained by the Hospitals from the 3rd respondent before proceeding with the
treatment/surgeries under the Cashless Model provided by the NHIS-2016, vide letter, dated 07.12.2016, R-4/Hospital addressed the 3rd
respondent, which is the agent of the 2nd respondent /United India Insurance Company, entrusted by R-2 with the work of providing approvals
for treatments/surgeries. But R-3, by reply dated 08.12.2016, denied authorization by stating that the illness is not covered under the Scheme and,
as a consequence, R-4 is insisting upon the petitioner to meet the medical expenses personally. According to the learned counsel, when the very
ailment for which treatment is sought to be pursued by the petitioner is very well covered by the Scheme as per Annexure- IIA thereof and further,
the 4th respondent also being one of the Network Hospitals coming under the realm of the Scheme, the denial of authorization by R- 3/Agency of
R-2/Insurance Company is a clear arbitrary action. By pointing out the aspect that the petitioner is battling for his life with feeble and fragile heart
condition and that if he does not receive the treatment timely, anything untoward may happen to him, learned counsel pleaded that this is an
exceptional case which deserves a positive direction, as prayed for.
Per contra, learned Government Advocate appearing for the first respondent would submit that, no doubt, the petitioner had approached the 4th
respondent/Hospital, which is a Network Hospital under the Scheme for the Coronary Angiography Test and Cardiac ailment Surgery and AICD
(Automated Implantable Cardioverter Defibrillator), at a cost of Rs.7 lakhs approximately for the said surgery. Under the NHIS-2016, the
Network Hospital, before proceeding with the treatment, should obtain the approval of the Insurance Company, enabling the patient/Government
Employee to avail the Cashless Scheme. In the instant case, the line of treatment, on examination, was found by the Agency as not the one covered
under the Scheme and hence, the claim could not be admitted by the Insurance Company. According to the first respondent, AICD is a device
implantable in the body able to perform cardioversion, however, the same not being a Permanent Pacemaker and only a Defibrillator, the request
came to be rejected. Further, the opinion offered by the Government Doctor/Associate Professor of Cardiology - Dr.M.A.Arumugam is also to
the effect that usually, Permanent Pacemaker Implantation is not equated with AICD which is defibrillator. Accordingly, the case of the petitioner
not being covered by the NHIS-2016, his claim was rightly rejected; hence, the writ petition deserves to be dismissed, he argued.
Learned Standing Counsel appearing for the Insurance Company, by stating that the Insurance Company is not liable for reimbursement to the
employees who resort to unapproved procedures, would submit that both Coronary Angiogram as well as Radio Frequency are diagnostic
procedures not covered under the Scheme and also, AICD is not considered as a pacemaker implantation. Therefore, the Insurance Agency and
Company are absolutely right in denying the plea of the petitioner, he stated.
This Court, after examining the Scheme in question as well as the claim and counter-claim of both sides, hardly finds any substance in the
justification given by the respondents to reject the claim of the petitioner, for the following reasons.
It is an admitted case that the petitioner is a subscriber to the NHIS-2016 and the monthly premium is being deducted from his salary, that the
4th respondent/Hospital is a Network Hospital within the realm of the Scheme and that the amount sought to be claimed is also within the limit
prescribed therein. In order to find out as to whether the ailment falls under the categories provided by the Scheme, Annexure-II/Category-A can
be usefully referred to and the same is given below:
CARDIOLOGY AND CARDIO THORACIC SURGERY Heart Surgeryincluding
(a) Coronary By-pass Surgery (CABG)
(b) Valve Replacement and Other Valvulo Plastics
(c) Correction of all congenital Heart Diseases
(d) Angioplasty and PTCA Stent
(e) Baloon Valvuloplasty
(f) Permanent and Temporary Pacemaker Implantation
(g) Embolectomies for Peripheral Artery Embolism
(h) Surgeries for Repair of Aneurysm
(i) Enhanced External Counter Pulsation Therapy (EECP)
Further, Annexure-IIA - List of Specified Illness for the Enhanced Limit of Rupees Seven Lakh and Fiffy Thousand, contains the following
category under the Column ''Name of Diseases, Treatments and Surgeries'' -
Complex Open Heart Surgeries and Implants
A combined reading of both the above Annexures under the Scheme would make it clear that the treatment and surgery involving implantation have
been recognized in a broad manner under the Scheme. In other words, when therapeutic procedures like Angioplasty/PTCA Stent/Baloon
Valvuloplasty are categorized in Annexure-II, it is not known why the Insurance Company/Agency are so keen to constrict the scope and range of
the Scheme by smartly dissecting a combined procedure involving both diagnostic procedure and treatment, for depriving the petitioner of availing
the life-saving treatment. In fact, it is not even denied by the Insurance Company, in their counter affidavit, that AICD is a device implantable inside
the body to perform cardioversion (a medical procedure by which an abnormally fast heart rate is converted to a normal rhythm using electricity or
drugs) and defibrillation, (stopping of muscle contraction in the heart by administering a controlled electric shock, to allow restoration of the normal
rhythm). Hence, the requirement to implant a device inside the body of the patient/petitioner is never denied by any of the respondents.
Even though an attempt was made to thwart the claim of the petitioner through the opinion offered by Cardiologist-Dr.Arumugam, on a perusal
of the copy of the opinion offered by him, it is seen that the Report is so shallow that except to state that AICD is equated with Permanent
Pacemaker Implantation, there is no direct reason therein, either stating that the question of implanting a device does not involve in the treatment
procedure or opining that what was claimed by the petitioner does not fall under the scope of the policy. Therefore, it is highly unsafe to rely on
such superficial Report.
This Court has also perused the earlier observation made in this matter on 03.03.2017. While adjourning the matter to 10.03.2017, it was
observed that in the interrugnum period, if anything happens to the petitioner, the 1st respondent/State may be held liable and responsible. But, in
spite of such sharp observation, it is not known why, till date, the first respondent is not able to give clear-cut instructions in this case where the life
of the petitioner, who is none else than the employee of the State, is at imminent risk and he is in acute need of immediate medical treatment. His
previous medical history reveals that he has been suffering from heart ailment for the past 15 years and despite having undergone a by-pass
surgery, the illness got aggravated and, only by taking up the treatment advised by the 4th respondent, he could save his precious life. This Court,
on perusing the Rejection Report of the Insurance Agency, finds that it is an one-line rejection order to the effect ""illness procedure not covered
hence denied"". Vital factors like, medical history of the policy-holder, intensity of the ailment, urgency for pursuing the treatment, etc. have not at all
been taken into account. One thing is apparently clear that the endeavor of the Insurance Agency was only to deprive the benefit of the policy
which the petitioner seeks to save his life. Therefore, when the estimated claim for the procedure and treatment is Rs.6,60,550/-, which is below
the limit of Rs.7 lakhs prescribed under the Scheme, this Court finds no impediment in the way of the Insurance Company to accede to the request
of the petitioner.
Thus, on an overall assessment, this Court is of the view that the respondents are absolutely unjustified in denying the plea of the petitioner for
pursuing treatment through Cashless Scheme under NHIS-2016. Accordingly, the 2nd respondent/Insurance Company is hereby directed to issue
the authorization letter to the 4th respondent for the cashless treatment of the petitioner under NHIS-2016, within two days from the date of
receipt of a copy of this order. Writ Petition is ordered accordingly, however, there will be no order as to costs.