Madras High Court
B.Maheshwaran vs The Project Director on 6 December, 2023
Author: N.Anand Venkatesh
Bench: N.Anand Venkatesh
W.P.(MD)No.18811 of 2021
BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT
DATED : 06.12.2023
CORAM
THE HONOURABLE MR.JUSTICE N.ANAND VENKATESH
W.P.(MD)No.18811 of 2021
B.Maheshwaran ... Petitioner
Vs
1.The Project Director,
Tamil Nadu Health System Project(TNHSP),
3rd Floor, DMS, Annex New Building,
259, Anna Salai, Teynampet, Chennai.
2.The Vigilance Officer,
CMCHIS Project Office,
Chief Minister’s Comprehensive Health Insurance Scheme,
No.226, Om Sakthi Tower, Kilpauk Garden Road,
Kilpauk, Chennai-600 010.
3.The Administrative Officer,
Vikram Multispeciality Hospital,
Ring Road Junction,
Near Pandi Kovil, Madurai.
4.United India Insurance Company,
Represented by its Regional Manager,
Madurai. ... Respondents
(Respondent No.4 is suo motu impleaded vide Order of this Court dated
06.12.2023 in W.P.(MD).No.18811 of 2021)
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https://www.mhc.tn.gov.in/judis
W.P.(MD)No.18811 of 2021
PRAYER: Writ Petition filed under Article 226 of the Constitution of
India for issuance of Writ of Mandamus, directing the respondents to take
action for the petitioner’s Grievance UGN.No.042020/54518 dated
10.04.2020 under Chief Ministers Comprehensive Health Insurance
Scheme URN.No.0133271741556110000009 cum Ayusman Bharath
Pradhan Mandri Jan Arokya Yojana and directing the third respondent to
pay compensation of three lakh to the petitioner’s family.
For Petitioner : Mr.B.Mahendrarajan
For R-1 : Mr.A.K.Manikkam,
Special Government Pleader
For R-2 : Mr.G.Prabhu Rajadurai
For R-3 : Mr.S.Tamizharasan
ORDER
The United India Insurance Company, represented by its Regional Manager, Madurai, is suo motu impleaded as the fourth respondent in this Writ Petition.
2. This Writ Petition has been filed for issuance of writ of mandamus directing the respondents to take action on the grievance expressed by the petitioner and to reimburse the medical expenses incurred for the treatment of the petitioner's father under the Chief Minister's Comprehensive Health Insurance Scheme.
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3. The case of the petitioner is that his father suffered from Chronic Kidney Disease, Hyponatremia and Anemia. On 09.04.2020, the father of the petitioner was admitted in the third respondent Hospital for treatment. The petitioner also approached the Hospital Authority and informed that the treatment is taken under the Chief Minister's Comprehensive Health Insurance Scheme. The request made by the petitioner was rejected by the Hospital and hence, the petitioner made a complaint in this regard. According to the petitioner, he had spent more than Rs.1,50,000/- (Rupees One Lakh and Fifty Thousand only) and he was not able to incur any more expenses. As a result, he got his father discharged on 13.04.2020 and unfortunately, the petitioner's father died on 20.04.2020. It is under these circumstances, the petitioner has approached this Court seeking for reimbursement of the medical expenses incurred for the treatment of the petitioner's father.
4. When the matter came up for hearing on 09.11.2023, this Court passed the following order:-
3/15https://www.mhc.tn.gov.in/judis W.P.(MD)No.18811 of 2021 “The main issue that was raised by the learned counsel appearing for the petitioner is that his father was suffering from Chronic Kidney Disease (CKD), Hyponatremia and Anemia. The second respondent has filed a counter-affidavit stating that the Chief Minister’s Comprehensive Health Insurance Scheme does not cover the treatment for Hyponatremia and Anemia.
2. The learned counsel appearing for the petitioner submitted that the father of the petitioner was suffering from Chronic Kidney Disease and this is directly covered under the Scheme and to substantiate this submission, the petitioner relied upon Page No.8 of the typed set of papers which provides for the list of packages coming under the head of Nephrology.
3. The above issue has not been dealt with by the second respondent in the counter affidavit.
The only clarity that is required for this Court is to see if the Chronic Kidney Disease that was suffered by the father of the petitioner is covered under the package. The second respondent is directed to give a clarity on this issue. The third 4/15 https://www.mhc.tn.gov.in/judis W.P.(MD)No.18811 of 2021 respondent is also directed to file a counter in this case.
4. Post this case under the caption “For Orders” on 27.11.2023.”
5. When the matter was taken up for hearing today, an additional affidavit of the second respondent was filed along with all the relevant documents. The relevant portions in the additional affidavit are extracted hereunder:
“ 5. I submit that in any case the condition of the Patient and the case history would not make it possible to cover the medical expenses under the scheme. The case of the Petitioner's father was examined by our Chief Medical Officer and that on his opinion the Petitioner's father did not undergo any treatment that would be covered under the Scheme. The following is the observation of the Chief Medical Officer with reference to the case of the Petitioner's father.5/15
https://www.mhc.tn.gov.in/judis W.P.(MD)No.18811 of 2021
1. As per CT scan report dated 02-03-2020, patient had Prostatic hypertrophy with intravesical component causing obstructive uropathy of both kidneys.
Cystitis - Bladder inflammation/infection. Both Kidneys were normal in position, Moderate Hydronephrosis of both kidneys without any stone obstructive uropathy - caused by Prostate swelling. (Annexure-1) Blood test with Urea and Creatinine values, Urine tests, e-GFR test not available for CKD. No details of treatment available - whether patient was advised surgery of Prostate or he was catheterized to relieve him of his symptoms is not available.
2. As per abdomen USG report dated 13-03-2020, patient had moderate Prostatomegaly causing bladder outlet obstruction with obstructive uropathy and Chronic cystitis inflammation/infection. (Annexure 2) Bladder 6/15 https://www.mhc.tn.gov.in/judis W.P.(MD)No.18811 of 2021 Inference-
Ultrasound abdomen also shows
Hydroureteronephrosis without any stone
obstructive uropathy - caused by Prostate swelling - Not reported in Ultrasound report (Impression).
Urea and Creatinine values not available nor any prescriptions. All the symptoms were caused by Prostate swelling however treatment details are not available. Whether patient was advised surgery relieve him of his symptoms is not available.
It is clear that patient was not catheterised in the 11 days after CT taken on 2 March and hence his symptoms persisted.
3. As per blood investigation reports dated, patient had hyponatremia, anaemia and elevated renal parameters. (Annexure 3)
4. CT report dated 9 April 2023-patient had Prostatic hypertrophy with cystitis and obstructive uropathy of both kidneys. (Annexure 7/15 https://www.mhc.tn.gov.in/judis W.P.(MD)No.18811 of 2021
4) Both Kidneys were normal in position, Moderate Hydronephrosis of both kidneys without an stone.
Inference-
Symptoms of obstructive uropathy-caused by Prostate Swelling Bladder Catheterized-known when.
5. Hospital report issued on 13 April, 2020-shows The patient Mr. Balakrishnan admitted t Viliam Multi Speciality Hospital, Madurai on 09-04-2020 with Viskammplaints of Dionrientation for days, drowsy for few days and loss of appetite since last 15 days. He is a known patient of chandle kidney disease. He was treated for the management of Hyponatremia and anemia. His treatment has been with 3% NACI, Junit Packed Cell (Blood) transfusion done additionally Antibiotics, Antacids, Renal protective drugs, it was mentioned in medical report that his relatives were not willing for further treatment and he was discharged from the hospital against medical advice. (Annexure-5) As per Hospital report issued on 13, April 2020, the patient was admitted for disorientation, blood 8/15 https://www.mhc.tn.gov.in/judis W.P.(MD)No.18811 of 2021 investigations showed Hyponatremia, Anaemia and elevated renal parameters. The common causes of Hyponatremia -is infection (more common in elderly people) (WBC- within range, High or Low Blood sugar (normal as per blood report), Head injury or Stroke or Brain related issues-However CT Brain is not available. Anaemia in the elderly is associated with nutritional deficiencies and chronic disorders. Based on past History CT-Abdomen has been taken. CT abdomen is not required to diagnose CKD, USG abdomen, Urine analysis and output reports are enough.
Further the treatment has been 3% NACL, Junit Packed Cell (Blood) transfusion done. Despite Creatinine being above 7.2mg/dl during the entire course of Hospital treatment between to 23 April)-Haemodialysis has not been advised or done as per Hospital report. The above clearly indicates that the treatment has been given for Hyponatremia, Anaemia, the underlying elevation of renal parameters were predominantly due to the Obstructive uropathy caused by Prostatomegaly which has been identified in 2 March 2020 as per available 9/15 https://www.mhc.tn.gov.in/judis W.P.(MD)No.18811 of 2021 reports. Chronic Kidney Disease related reports are not available and past treatment reports are not available
6. The patient Mr.Balakrishnan was treated medically for Hyponatremia and anaemia, which is not covered under the scheme, the treatment for Chronic Kidney Disease is covered under CMCHIS
6. I submit that in any case the patient was discharged against medical advice and has not been administered for treatment which is met covered under the Scheme. On verifying the Vikram Multi Specialty Hospital... Madurai performance under CMCHIS from 2017 to 2022, they had treated 1,478 patients under Nephrology packages and in view of the aforesaid circumstances this Writ Petition may be dismissed.”
6. Heard the learned counsel on either side.
7. Mr.Prabhu Rajadurai, learned counsel appearing on behalf of the second respondent submitted that the petitioner's father was 10/15 https://www.mhc.tn.gov.in/judis W.P.(MD)No.18811 of 2021 suffering from Chronic Kidney Disease. But, however, he did not take treatment for this ailment and treatment was given by the third respondent only for Hyponatremia and Anemia. These treatments were not covered under the Scheme and therefore, the amount was not reimbursed to the petitioner.
8. In the considered view of this Court, on carefully going through the additional affidavit filed by the second respondent and also the materials placed before this Court, it is seen that the petitioner's father was diagnosed to be suffering from the Chronic Kidney Disease. The treatment that was given to the petitioner's father is available in the medical report dated 13.04.2020 and for proper appreciation, the same is extracted hereunder:
“Patient admitted with complaints of Disorientation since 4 days. History of loss of appetite since last 15 days and drowsy since last few Days. Known case of CKD on treatment. Blood investigations done showed byponatremia, anemia, and elevated renal parameters. Opinion obtained from Physician and Nephrologist and 11/15 https://www.mhc.tn.gov.in/judis W.P.(MD)No.18811 of 2021 Patient treated with Inj 3%NACI, antibiotics, Sodamint, antacids, Nephro protective drugs and other supportive measures. I unit PCV transfusion done. Patient condition and plan of treatment explained to Patient relatives but they are not willing for further management hence discharged Against medical advice.”
9. It is clear from the above that the petitioner's father was diagnosed with Hyponatremia and Anemia and also Elevated Renal Parameters. The treatment was also given for the same by prescribing necessary drugs and providing supportive measures. Since there was some confusion regarding the reimbursement under the Scheme, the petitioner was not in a position to continue with the treatment in the third respondent Hospital and hence, he got his father discharged against medical advice.
Unfortunately, the petitioner's father died on 20.04.2020. It cannot be stated that the petitioner's father was given treatment only for Hyponatremia and Anemia. He was diagnosed with Chronic Kidney Disease and treatment was given for the same by prescribing necessary drugs and also providing supportive measures. The Scheme must be given a wide interpretation and the claim for reimbursement should not be 12/15 https://www.mhc.tn.gov.in/judis W.P.(MD)No.18811 of 2021 rejected on hyper-technical grounds. This Court is satisfied that the petitioner is entitled for reimbursement under the Scheme, since the treatment was also given to the petitioner's father towards the Chronic Kidney Disease suffered by him.
10. The learned counsel appearing for the petitioner submitted that the petitioner had incurred total expenses of Rs.91,455/- (Rupees Ninety One Thousand Four Hundred and Fifty Five only) for the treatment and the petitioner also has necessary bills to substantiate the same.
Accordingly, there shall be a direction to the petitioner to make a fresh representation to the first respondent along with all the relevant documents seeking for the reimbursement of the sum of Rs.91,455/- (Rupees Ninety One Thousand Four Hundred and Fifty Five only) under the Chief Minister's Comprehensive Health Insurance Scheme. On receipt of the same, the first respondent shall direct the impleaded fourth respondent Insurance Company to settle the amount to the petitioner within a period of six (6) weeks thereafter.
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11. It is made clear that the peculiar facts of this case impelled this Court to issue the above direction and more particularly, since the entire episode had taken place during the pandemic period. During this period, the hospitals were over-worked in handling Covid patients and lot of confusions prevailed and as a result, there was no clarity with regard to the type of treatment that was given to the petitioner's father. Therefore, the direction issued in this Writ Petition cannot be taken as a precedent in any other case.
12. This Writ Petition is disposed of in the above terms. No costs.
06.12.2023 NCC:yes/no Index:yes/no Internet:yes/no tsg To
1.The Project Director, Tamil Nadu Health System Project(TNHSP), 3rd Floor, DMS, Annex New Building, 259, Anna Salai, Teynampet, Chennai.
2.United India Insurance Company, Represented by its Regional Manager, Madurai.
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