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HARPREET SINGH BRAR, J. (ORAL) --

PRAYER

1. The present civil writ petition has been filed under Articles 226/227 of the Constitution of India for issuance of a writ in the nature of mandamus directing the respondents to consider the case of the petitioner and thereafter, release the entire amount of bills i.e. Rs.7,42,630/- along with interest @ 18% per annum which was paid by the petitioner as indoor patient from 19.04.2023 to 22.04.2023 to the Paras Hospital, Panchkula for treatment or in the alternative directing the respondents to take a decision on legal notice dated 17.11.2023 (Annexure P-3).

CONTENTIONS

2. On 02.12.2025, the following order was passed:-

“CM-11132-CWP-2024

The present application has been filed under Order 22 Rule 1, 2 & 3 of CPC read with Section 151 of CPC for impleading the legal heirs of the petitioner.

Notice in the application.

Learned State counsel as well as counsel for respondents No.4 & 5 put in appearance and accept notice on behalf of the respondent-State, respondent No.4 and respondent No.5, respectively and submits that they have no objection if the legal heirs of the deceased-petitioner are impleaded.

In view of the averments made in the application and in view of the statement made by the learned State counsel as well as counsel for respondents No.4 & 5, the application is allowed and the legal heirs of the petitioner as mentioned in para No.4 of the application are allowed to be impleaded as prayed for.

Amended memo of parties is taken on record.

Registry is directed to do the needful.

CWP-28175-2023

The dispute in the present writ petition pertains to the petitioner’s entitlement to medical reimbursement. The concerned hospital has filed its written statement and annexed the tax invoice containing a complete cost breakup.

The State of Haryana has taken a specific stand that all admissible benefits have been released to the petitioner in accordance with the applicable policy dated 14.07.2020. However, learned counsel for the petitioner contends that the petitioner, who was 85 years of age, visited the respondent-hospital on 19.04.2023 with symptoms indicative of critical Coronary Artery Disease and, on medical advice, was admitted the same day and discharged on 22.04.2023 after undergoing angioplasty. It is submitted that the petitioner was assured that the package would cover the treatment and diagnostic procedures, including admission charges, consultation fee, procedural charges, anaesthetist’s fee, cost of surgical disposables, consumables, gas charges, and surgical charges, as stipulated under the heading ‘Package Rate’ in the policy. Contrary to this, respondent No.5-Hospital charged Rs.1,05,000/- for the angiography-cum-angioplasty package and Rs.30,000/- for the Rotablation package as per tax invoice (Annexure R-5/1), while an amount of Rs.6,02,469.64/- was separately charged towards medicines and consumables, which is stated to be grossly disproportionate to the approved package cost. It is further submitted that the petitioner, being an elderly retiree, was not provided complete information by the hospital regarding the basis of such charges.

In view of the conspicuous facts and circumstances of the case, respondent No.1 is directed to file an affidavit deliberating therein how the rate of the packages are fixed once the policy dated 14.07.2020 provides that ‘package rate’ will include the following:-

1. Definitions:

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iii) ‘Package Rate’ a lump sum amount charged by the empanelled Private Hospitals for packages/procedures.

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2. Guidelines for implementing Package/Implant Rates

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ii) The "Package rate" shall mean and include lump sum cost of inpatient treatment/day care/diagnostic procedures for which patient goes to hospital. This includes all charges pertaining to a particular treatment/Procedure including admission charges, visit fee/consultation fee, Patient's diet, monitoring charges, preoperative investigation charges, investigation charges, operation charges, anaesthesia charges, operation theatre charges, procedural charges/surgeon's fee, anaesthetist's fee, cost of surgical disposals and all sundries used during hospitalization, consumables, gas charges, Surgical charges/OT assistant charges, cost of medicine used during hospitalization, physiotherapy charges, nursing care charges for its services, routine post operative stay in ICU, blood transfusion (blood grouping, cross matching, blood or component, Transfusion) and medicines for a period of 7 days after discharge from the hospital etc.’

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4. Additional Guidelines:-

a) Apart from identified packages, any non-package procedure will be worked out as under:-

i. Room rent- as per the entitlement of the beneficiary.

ii. Lab and Diagnostics- As per the rates fixed (Annexure-I)

iii. Medicines and consumables Rs.1750/- per day. This will exclude high cost injections such as Anti-D, Anti Haemophilic Factors, Thrombolytic treatment (Streptokinase), Anti Cancer drugs, Antibiotics (the per day cost of which is more than Rs. 2000/- irrespective of number of doses), etc.

iv. The high cost injection is defined as an injection, the per day cost of which comes out to be more than Rs.2000/- after decreasing 30% on MRP of purchased injection by the hospital. In such case, health facility shall give undertaking that no cheaper brand of same composition or molecule is available in their inventory/ stock.”

Respondent No.1 is further directed to provide the details of the regulatory mechanism governing the fixation of rates by empanelled hospitals. Prima facie, it appears that empanelled hospitals, in order to attract patients, have lowered the package rates by excluding the cost of medicines and consumables from the package, which are then billed separately. Respondent No.1 shall also clarify whether such a practice is permissible under the applicable policy framework or if it is being adopted to circumvent the liability.

Needful be done within a period of two weeks.

List on 18.12.2025.”

3. In compliance thereof, the affidavit dated 15.01.2026 of the Director General Health Services, Haryana, has already been filed and the same is available on record. Perusal thereof, indicates the following:-

“2. That point wise status report is as under:-

(i) How the rate of the packages are fixed once the policy dated 14.07.2020 provides that package rate will include (the essential charges as mentioned in the Policy):-

(a) That it is respectfully submitted that the package rates for common procedures have been fixed by the Haryana Government after detailed deliberations and consultations with medical specialists from various departments of Government hospitals and after undertaking comparative analysis with the prevailing tariffs of leading private empanelled hospitals, Central Government Health Scheme (Delhi NCR rates) & package rates fixed by insurance companies.

(b) That as per Para 1(b) of the Haryana Government Instructions dated 14.07.2020 (Annexure R-1), empanelled hospitals are required to provide treatment on 1340 procedures (different packages) listed in Annexure-l and II at the prescribed package rates/implant rates (wherever implant rates have been notified by the Government of India or State Government). These package rates are applicable strictly to the procedures enumerated in Annexure-1.

(c) fee/consultation That the definition and scope of "Package Rate" is clearly laid down in Para 2(b)(ii) of the Instructions dated 14.07.2020, which provides that the package rate is a lump-sum cost inclusive of admission charges, visit fee, Patient's diet, preoperative investigation charges, investigation charges, operation charges, anaesthesia charges, operation theatre charges, procedural charges/surgeon's fee, anaesthetist's fee, cost of surgical disposals and all sundries used during hospitalization, consumables, gas charges, Surgical charges/OT assistant charges, cost of medicine used during hospitalization, physiotherapy charges, nursing care charges for its services, routine post operative stay in ICU, blood transfusion (blood grouping. cross matching, blood or component, Transfusion) and medicines for a period of 7 days after discharge from the hospital etc.

(d) It is further submitted that there is no package rate for Intravascular lithotripsy (IVL) So it is a non package procedure. Accordingly, reimbursement of the IVL catheter, being a consumable, is admissible as per Para 4(a)(iii) of the Haryana Government Instructions dated 14.07.2020, which allows reimbursement of medicines and consumables at Rs.1750 per day and high-cost injections exceeding Rs.2000 per day

(e) That it is respectfully submitted that in the present case, as per the medical bill issued to the petitioner by the empanelled private hospital, namely Paras Hospital, Panchkula, vide Bill No. PKL241PCS244 dated 24.04.2023, the hospital has charged the beneficiary as per the package rates of different procedures in Annexure-I of the Haryana Government Instructions dated 14.07.2020 for:

(a) Angioplasty as per Package No. 26/26,

(b) Rotablation as per Package No. 27/27, (50% of the package rate, in accordance with Para 4(b)(ii)) of policy.

* It is further submitted that under the Angioplasty package, the fixed cost of three stents, along with Injection Eptifibatide/Abciximab/Tirofiban, Thermo suction catheter (wherever applicable) and room rent, are reimbursable in addition to the package rate,.

* Under the Rotablation package, the cost of the Rotablator up to 250,000/- or the actual cost, whichever is less, is reimbursable in addition to the package rate.

* Hospital has not charged Medicines and consumables separately for treatment related to Packages mentioned above.

* It is submitted that the hospital has charged the cost of Stents and Rotablator under the head "Medicines and Consumables" instead of "Implant/Device" which are reimbursable to the beneficiary in addition to package rate as per Haryana Government Reimbursement policy.

(f) Detailed breakup of the bill and Admissibility as per reimbursement policy dated 14.07.2020

(g) However, it is pertinent to mention that in case an employee opts for a category of room or implant beyond his/her entitlement or beyond the rates fixed by the Government, it is responsibility of the hospital to explain the same to the beneficiary and obtain a written undertaking from the beneficiary that such additional expenditure shall be borne by the beneficiary as provided under Para 2(b)(vi) of the Instructions dated 14.07.2020.

(ii) To provide the details of the regulatory mechanism governing the fixation of rates by empanelled hospitals:-

That it is submitted, that the Health Department is only the nodal department for implementing the policy of the Government of Haryana with regard to formulation of medical reimbursement rules and empanelment of hospitals for Haryana Government employees and pensioners..

Regulatory mechanisms governing empanelled hospitals include:-

* Empanellement of hospitals is subject to their adherence to all statutory Rules/Guidelines/Acts/Notifications (including notified package rates) issued by the State Government from time to time.

* Health department has designated various teams for surprise checks of Hospital.

* Health department reserves the right to call for record of treatment of any patient from any empanelled hospital to ensure no malpractice takes place.

* Scrutiny/Audit/Verification of Medical bills by the competent authority of respective department before reimbursement.

* Any overcharged amount identified shall be refunded by the hospital to the beneficiary.

* In case of violation of policy provisions, the hospital may be de-empanelled.”

4. Further, the affidavit on behalf of respondent No.5 indicates that the petitioner was admitted in the hospital on 19.04.2023 to 22.04.2023 with a symptom of Critical Coronary Artery Disease which needed immediate angioplasty & stenting. Instead of performing the aforesaid procedure, in order to address the heavily calcified coronary blockage, alternative techniques, namely, Rotablation and Intravascular Lithotripsy (IVL), were employed. These are relatively recent technologies, available in India for the past four years and are widely recommended worldwide. The balloons used in these procedures differ from those utilized in standard and routine angioplasty Therefore, it has been submitted on behalf of respondent No.5 that IVL is not a part of angioplasty package. As such, the amount on account of IVL is charged separately which is not a part of the package. Further, there is no denial to the fact that the aforesaid procedure was conducted in view of the fact that the petitioner was suffering from heavily calcified Coronary Blocks and in order to preserve the life of the petitioner, he was subjected to the new IVL procedure.

5. Learned State counsel refers to the affidavit of the Director General, Health Services, Haryana, and submits that the cost of items used in the IVL technique is reimbursable under Para 4(a)(iii) of the policy, which provides for reimbursement of medicines and consumables up to Rs.1750/- per day. This amount is in addition to Rs.2,000/- per day, admissible in case any high-cost injections are administered to the petitioner.

OBSERVATION & ANALYSIS

6. I have heard learned counsel for the parties and perused the records with their able assistance. It transpires that the petitioner was suffering from critical coronary artery disease requiring immediate angioplasty and stenting, to treat the petitioner. However, upon examining the petitioner, the doctors found that there were heavily calcified coronary blocks, which would not be cured by routine balloon angioplasty and stenting. The procedure that needed to be adopted for treatment of such heavily calcified coronary blocks would be the new and advanced procedure named Rotablation & Intravascular Lithotripsy (IVL), which uses a specially designed catheter to break the calcified coronary blocks. As such the same procedure was adopted to treat him. This factual position is not disputed, rather it’s even corroborated by the respondent’s written statement.

7. The ground relied upon by the respondents to deny the petitioner for their claim is that the Coronary Balloons used in IVL are not the same Balloons used in normal and routine angioplasty, therefore IVL is not part of angioplasty package. Further, a bare perusal of the compliance report of the Director General Health Services stipulates that, IVL is not covered in the package rate and thus its a non package procedure, and is covered under the head “Medicines and Consumables” instead of “Implant/Device” which are reimbursable to the beneficiary in addition to package rate.

8. It seems that it is undisputed that the petitioner needed the IVL, as the normal angioplasty would be ineffective, as such the only course of action available was taken to treat the petitioner accordingly. The factum of treatment, the genuineness of the medical bills of the petitioner are not in dispute. As such the respondents are denying the claim of the petitioner on hyper-technical approach.

9. It appears that the respondents have chosen to adhere to the policy in its letter, while turning a blind eye to its spirit and true objective. In doing so, they have forgotten that a policy meant to preserve life cannot be allowed to become a procrustean bed of rigid literalism.

10. The true aim and objective of providing medical support to employees and retirees is rooted in the constitutional vision of a welfare state. These policies are meant to be fiscal instruments of social security, designed to protect the beneficiary in times of medical distress. As such when life hangs in balance, the policy must bend toward the living, not stand rigid upon its lexicon. The policy, designed to heal, cannot be permitted to become an instrument of denial on hyper-technical grounds.

11. On one hand, the State accepts that the only viable course of treatment for the petitioner was IVL, while on the other, it denies the claim solely on the ground that the procedure is not covered in the package list and differs from routine angioplasty. This act of the State is in direct contravention of its constitutional obligation and is tantamount to defeating the spirit of the very policy it seeks to enforce. To accept the treatment as medically necessary, yet deny its cost on a technical ground, is to render the fundamental right to health and medical aid, a hollow promise, striking at the very root of fairness.

12. Further, the stand of the respondents that intravascular lithotripsy (IVL) and angioplasty are distinct and unrelated procedures is fundamentally misconceived. As is evident from the medical literature itself, IVL is an endovascular angioplasty technique employing a balloon catheter that delivers acoustic shockwaves to modify heavily calcified plaques and facilitate arterial dilatation in lesions where conventional angioplasty carries a higher risk of inadequate dilatation, dissection, or rupture. A perusal of the article titled Intravascular lithotripsy angioplasty for treatment of atherosclerotic coral-reef occlusion of the infrarenal aorta and its bifurcation, published by the National Center for Biotechnology Information, established under the U.S. Department of Health and Human Services¹ [¹Michele Piazza et al., Intravascular Lithotripsy Angioplasty for Treatment of Atherosclerotic Coral-Reef Occlusion of the Infrarenal Aorta and Its Bifurcation, 9 J. VASC. SURG. CASES INNOV. TECH. 101106 (2023) (PMCID: PMC10011829), https://pmc.ncbi.nlm.nih.gov/articles/PMC10011829/] expressly describes the procedure as “intravascular lithotripsy angioplasty” and further records that the “Shockwave IVL device … uses an angioplasty balloon to deliver acoustic shockwaves to the arterial wall,” thereby demonstrating that IVL is a specialised modality of angioplasty intended for heavily calcified vascular lesions where ordinary balloon angioplasty may not be sufficient.

13. This court cannot countenance the hyper technical approach adopted by the respondents to deny the reimbursement of a valid medical claim of the treatment which was essential and necessary to preserve the life of the petitioner. Respondents can’t be allowed to refuse to acknowledge an advanced and specialised form of treatment, even though it falls within the same branch of angioplasty and, more critically, was the only course of action available to save the petitioner's life. Compassion has been sacrificed at the altar of technicality. This approach defeats the very purpose of a medical aid policy.

14. This Court is not dealing with a matter of mere administrative reimbursement of a routine nature. The subject matter here concerns the life and health of a person suffering from critical coronary artery disease, a life-threatening cardiovascular condition that leaves no room for error or experimentation. Every lock has its own key; every ailment its own cure. The test cannot be what is listed, the test must be what is medically necessary to save a life. If conventional angioplasty would not work, and IVL would work, the respondents cannot insist upon the former simply because it finds mention in a list.

15. Shockingly, what can be inferred from the respondents' stand is that, had the petitioner undergone conventional angioplasty, regardless of it being ineffective for his heavily calcified coronary blocks, the respondents would have happily reimbursed the same, because it finds mention in the package list, regardless of whether it saved the petitioner's life or not. This Court cannot accept such a hollow approach.

16. Further, this Court is unable to accept the argument raised by learned State counsel based on the affidavit of the Director General, Health Services, that the IVL technique and specifically the IVL catheter, falls within the ambit of "medicines and consumables" under Para 4(a)(iii) of the Haryana Government Instructions dated 14.07.2020. The said provision allows reimbursement of medicines and consumables at a meagre Rs.1,750 per day, a sum evidently intended for routine items such as syringes, gauze, dressings, or oral medications. To now claim that a specialized, shockwave-delivering angioplasty catheter, a life-saving device that costs Rs.3,50,000 and is the very essence of the IVL procedure qualifies as a mere "consumable" is not only irrational and illogical but also a gross misclassification. This Court cannot accept that the State, by the stroke of a pen, can reduce a complex interventional device to the level of a routine consumable. No prudent man would equate a life-saving angioplasty technique with routine consumables. Such an interpretation, if accepted, would render the constitutional right to health a mockery. The sphere of medicine and medical aid is a noble sphere. The State, in framing and implementing its policies, must reflect that nobility. It cannot be allowed to give primacy to the commercial angle, for a policy driven by commerce over compassion ceases to be a welfare policy.

17. The aforesaid procedure was undertaken to preserve the life of the petitioner; which satisfies the test of essentiality and emergency. Therefore, he is entitled to reimbursement of the same in terms of the judgment rendered by the Hon’ble Supreme Court in Surjit Singh v. State of Punjab 1996 INSC 157 and of this court in Kapoor Singh vs. State of Punjab and Others CWP-39210-2025.

CONCLUSION

18. In view of the peculiar facts and circumstances of the case, the present civil writ petition is disposed of with the following directions:-

1)The respondents are directed to reimburse the entire medical bill of the petitioner, along with interest @ 6% per annum, from the date it became due till the date of actual realization.

2)Respondent No.2 is directed to consider inclusion of the IVL technique within the package rates for coronary artery disease, including stenting and ballooning procedures, and to amend the policy accordingly.

3)Further, the Director General, Health Services, Haryana is directed to verify the package rates of all empanelled hospitals, either himself or through the concerned authorised Civil Surgeon. In case any of the empanelled hospitals are found to be violating the policy, appropriate corrective measures shall be taken, including cancellation of their license. The Director General shall further ensure that the cost of treatment is explained to the patient or their next of kin in a language they are familiar with, instead of merely obtaining signatures on cyclostyled proformas. The practice of artificially lowering package rates to attract patients initially, only to later charge separately for essential procedures, shall not be permitted.

4)Respondent No.2 shall undertake the aforesaid exercise and file a compliance report before this Court within a period of three months from the date of receipt of a certified copy of this order.

Order accordingly.

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