JUDGMENT
Manmohan Sarin, J.
1. Rule.
With the consent of the parties, writ petition is taken up for disposal.
2. Petitioner has filed this writ petition, seeking a writ of mandamus, directing the respondents inter alia to reimburse an amount of Rs. 79,548/- along with Rs. 27,806/- as losses, damages and interest @ 18% p.a. up to 9.2.2002, together with pendentelite and future interest at 18% p.a. from 10.2.2002, till the date of its realisation etc..
3. Petitioner, Mr. J.P. Kansal, was working as Dy. Manager with M/s. Gas Authority of India Ltd. Petitioner retired as Dy. General Manager on 28.2.1998. Respondents have a scheme for provision of medical facilities to retired employees. Petitioner availed of the scheme.
4. The writ petition shred off all unnecessary details and pleas can be confined to the petitioner’s claim for being reimbursed at 100% of the cost incurred for treatment at Escorts Heart Institute and Research Centre in October, 1999 instead of 75%. Besides claim is made for reimbursement of cost of medicines for post hospital treatment, traveling expenses etc.
5. Learned counsel for the respondent submits that the petitioner has been reimbursed as per the entitlement under the scheme. It is only in cases of serious diseases, which are listed in Annexure 1 (page 24 of the paper book), that a retired employee is entitled to 100% reimbursement otherwise reimbursement is confined to 75%. The petitioner who had undergone open heart surgery at Escorts Heart Institute and Research Centre (for short referred to as ‘EHIRC’) claims that his case is covered under the category of serious diseases. It would be relevant to reproduce the list of serous diseases, as given in Annexure 1 of the policy:
1. Tuberculosis incapacitating from work.
2. Cancer/Malignancy of any form
3. Leprosy
– Lepromatious
– Dimorphic
– any type incapacitating from work
4. Acute Mental Disorders
– Schiphrenia
– Maniac Depressive Psychosis
– Acute Endogenous depression with suicidal tendency
5. Heard Disease
– Myocardial infraction
– Chronic Congestive Cardiac Failure
– Complete Heard Block/Sick Sinus Syndrome leading to pace-maker implantation
6. Brain Diseases
– Brain Tumour
– Presinile Dementia
– Venus Sinus Thrombosis
– Parkinsons Syndrome Incapacitation from work
7. Paralysis
– Acute infective Plyhneurities & Landary’s type of ascending Paralysis
– Motor Neurone disease
– Paralysis of working limb following cerebral thrombosia/cerebral injuries
– Multiple Sclerosis
– Spinal injuries causing paralysis
8. Chronic Renal Failure
9. Cirrhosis of liver with established Portal Hypertension.
6. Petitioner claims that he was suffering from coronary heart disease and had suffered a myocardial infraction, which is listed as a serious disease under the heading heart disease. This is disputed by the respondents, who claim that even though the petitioner went through the open heart surgery, it was not a case of serious disease as classified under the scheme as noted above. A perusal of the test summary from the EHIRC shows recording of the complete history at the time of admission, the operational procedure undergone and the medicines prescribed as also the post operative condition of the petitioner till discharge. The relevant extract from the discharge summary may be reproduced:
“Mr. Kansal is a 59 year old gentleman who is a non hypertensive, non diabetic, non smoker with pleasing personality. He had chest pain on 20.10.99, later diagnosed as unstable angina and managed with NTG/Heparin. There is no history of myocardial infraction in the past. He was advised further investigation.”
7. The episode of 20.10.1999, is recorded as unstable angina. The EHIRC in their letter of 12.10.2001, further clarified that the petitioner was operated for coronary artery disease and not for myocardial infraction which could be the effect of coronary artery disease.
8. Learned counsel for the petitioner in an attempt to justify that the petitioner’s case fell within “myocardia infraction” and a serious heart disease as per the policy, sought to place reliance on two certificates. The first is at page 28 of the paper book (Annexure-3), wherein his treating Physician had made the recommendation for treatment in the following words:-
“Patient is advised early Coronary Angiography and Intervention for Post MI (Subtendo Cardiac Infraction) Angina and is referred to a Cardiac Institute for possible early intervention.”
The second a certificate of the physician, is dated 19.6.2000. It is to the effect that the petitioner had suffered an attack of myocardia infraction.
9. Considering the conflicting claims made as also the documents relied on by the parties it appears, prima facie, that the view and finding of the EHIRC, which is a super speciality hospital for cardiac diseases, deserves to be given credence over the certificates produced by the petitioner, one of which is issued after the event. A patient who comes for admission at EHIRC he is examined with reference to the prescriptions given by the recommending physicians, diagnostic tests are carried out and the case history is recorded. In the instant case, the case history as recorded and furnished by the petitioner did not reveal myocardial infraction and the discharge summary in fact records its absence. The certificates would not undermine the certification as given by the EHIRC. There is a categorical recording that the petitioner did not have any past history of Myocardia infraction. The record of treatment as filed also does not record a myocardial infraction. In any case, this is a disputed question of fact which cannot be determined in these proceedings. In these circumstances, petitioner’s case for reimbursement at the rate of 100% would not be admissible under the scheme of the respondents and direction as sought for can not be given with regard to reimbursement of 100% expenses. The petitioner has not challenged in the writ petition either the medical scheme for reimbursement or the classification of diseases as serious diseases.
10. Before parting with the case, it may be noticed that the respondents being a public sector company need to have a relook at the categories of serious diseases as given in this scheme. From a pragmatic and common sense point of view, it would be seen that a person like the petitioner, who was having a triple vessel disease with blockages of LAD 90%, LCx%, RCA 100%, was in a precarious state of health, with imminent potential of myocardial infraction. He went through a major surgery with four by-passes. It is unfortunate that even in these facts as per the criteria prescribed under the scheme, the case would not fall within serious heart diseases. The present day treatment visualises prevention of Myocardial infraction by giving treatment of drugs such as Strepokinese etc. The present classification of heart diseases by the respondents appears to be irrational and arbitrary and deserves to be amended with additions incorporated. Respondents could consider its rationalization by including critical coronary disease, having a potential of myocardial infraction. Respondents, in these circumstances, need to consider afresh the classification of serious diseases as prescribed under their scheme.
Petitioner has also the grievance that he has not been reimbursed the cost of medicines for post hospital treatment as also the traveling allowance. Having noted the shortcomings in the scheme, in a hard case like the petitioner, who has undergone open heart surgery with four by-passes, which entailed high risk to his life, respondents should sympathetically consider the petitioner’s claim keeping in mind that as a nodal employer, their concern ought to be equally for those who have served them well in past as well as of those who are presently serving.
The writ petition is disposed of with these observations and directions.