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2009 Supreme(Mad) 4124
High Court of Judicature at Madras
THE HONOURABLE MR. JUSTICE D. HARIPARANTHAMAN
N. Karunanithi
Versus
The Commissioner of Treasuries and Accounts & Others
W.P.No.14285 of 2007
Decided on : 09-10-2009
For the Petitioner:M/s. G. Elanchezhiyan, Advocate. For the Respondents: Mrs. C.K. Vishnupriya, (AGP).
The court established that advancements in medical treatments and procedures should be considered for reimbursement under government health schemes, and the ultimate decision on treatment lies with the treating doctor.
Headnote:
Medical Reimbursement - Government Employees - G.O.Ms.No.377, G.O.Ms.No.378 - Balloon Mitral Valvuloplasty - Coronary Angioplasty - Open Heart Surgery - Tamil Nadu Government Employees Medical Scheme, 1991
Fact of the Case:
The petitioner, a teacher, sought reimbursement for his wife's heart surgery expenses under the Tamil Nadu Government Employees Medical Scheme, 1991. The claim was initially refused by the second respondent.
Finding of the Court:
The court found that the surgery performed on the petitioner's wife was eligible for reimbursement under G.O.Ms.No.377 and G.O.Ms.No.378, and directed the respondents to disburse the funds for the medical expenses.
Issues: The main issue was the eligibility of the surgery for reimbursement under the government scheme.
Ratio Decidendi: The court interpreted the government orders G.O.Ms.No.377 and G.O.Ms.No.378 to include the specific heart surgeries, such as Balloon Mitral Valvuloplasty and Coronary Angioplasty, as part of open heart surgery eligible for reimbursement.
Final Decision: The court set aside the initial refusal and directed the respondents to sanction the permissible amount for the petitioner's claim without reference to objections raised.
The petitioner is a Secondary Grade Teacher in P.U. Middle School, Tittagudi Taluk, Cuddalore District. His wife was suffering from heart disease and no proper treatment was available at Tittagudi. She was thus referred to Ramachandra Hospital, Chennai. In a serious condition she was admitted on 010. 2002 in a serious condition and a major surgery (Balloon Mitral Valvuloplasty) was done on 10. 2002 for heart disease. She was discharged from the hospital on 110. 2002. The petitioner incurred an expense of Rs.88,214/-(Eighty Eight Thousand Two Hundred Fourteen only) towards the surgery charges and other medical expenses at Ramachandra Hospital, Chennai. He made an application for reimbursement of Rs.66,160/-being the 75% of the total expenses, under the Tamil Nadu Government Employees Medical Scheme, 1991.
2. The second respondent passed an order dated 29.05.2003, refusing to forward the application to the first respondent on the ground that the surgery performed on the wife of the petitioner is not the one prescribed by the G.O.Ms.No.400, Finance Department, dated 29.08.2000.
3. The petitioner filed O.A.No.3134 of 2003 to set aside the order of the second respondent and for a direction to the respondents to consider the claim for reimbursement, as per the Tamil Nadu Government Employees Health Fund Scheme.
4. Heard Mr.G.Elanchezhiyan, learned counsel for the petitioner and Mrs. C.K. Vishnupriya, learned Additional Government Pleader for the respondents.
5. The learned counsel for the petitioner states that the Government of Tamil Nadu issued G.O.No.377 Finance (Salaries) Department dated 110. 2005, wherein it is specifically included Baloon valvulo plasty as one of the heart surgeries that is eligible for medical reimbursement. While G. O.No.377 is relating to the serving Government employee, G.O.No.378 is issued on similar lines to retired Government Employees. It is further submitted that the Go.No.378 came for consideration by this Court in V. Palaniammal v. Secretary to Government, Finance (Salaries) Department, Chennai and another reported in (2008) 2 MLJ 852, and this Court held as follows in para 5 to 9, while relying on an order of this Court reported in 2006 (3) MLJ 641.
"5. I am of the view such a stand taken by the respondents cannot be accepted. Once the Hospital which gave treatment to the petitioner has certified that coronary angioplasty with stenting done on the petitioner on 09.07.2002 is equivalent to bypass surgery in order to provide fresh blood supply to the areas, which is supplied by the blocked artery due to advanced technologies it will have to be held that the same would fall well within the classified treatments under the erstwhile G.Os themselves. The revised detailed classification of the treatments mentioned in G.O.Ms.No.378 dated 110. 2005 by way of clarification can only be constructed as classification of the treatment of open heart surgery in different forms. In fact, Annexure I to G.O.Ms.No.378 dated 110. 2005 the Cardiology and Cardio Thoracic Surgery falling under I category as stated as under:
"I CARDIOLOGY AND CARDIO THORACIC SUPGERY
Open heart surgery including
.(a) Coronary By-pass surgery (CABG)
.(b) Valve replacement
.(c) Correction of Congenital complex heart diseases.
.(d) Angioplasty and PTCA stent
.(e) Baloon Valvulo Plasty
.(f) Permanent Pacemaker
.(g) Peripheral artery embolism
(Embolectories) By pass surgeries (Aneurysm repair)"
6. Such a detailed reference to different kinds of treatment falling under open heart surgery only shows that while all the above treatments falling under Clause a to g came within the common category of open heart surgery which was the treatment already provided for in the earlier Government Orders including G.O.Ms.No.400 dated 29.08.2000, the present expanded classification of the said open heart surgery cannot be construed as an inclusion of new treatment in order to state that for such a treatment the eligibility would arise on
