When a hospital says a patient cannot be treated by a routine heart procedure and must undergo a newer, more complex technique to survive, can the state still refuse reimbursement by saying that, “This is not in the package list?”
Deprecating the state’s stand, the Punjab and Haryana High Court has directed the reimbursement of a patient’s entire medical bill with interest after holding that a medical policy cannot be applied like a rigid billing chart when life itself is at stake. The Bench also directed the authorities concerned to consider the inclusion of the IVL technique within the package rates for coronary artery disease, including stenting and ballooning procedures, and to amend the policy accordingly.
The ruling by Justice Brar came in a case of a patient suffering from severe coronary artery disease. The doctors found that standard angioplasty would fail because the arteries were heavily calcified. The only viable treatment was an advanced procedure — IVL — a technique using a specialised catheter to break hardened blockages using shockwaves.
He asserted that: “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 found mention in the package list, regardless of whether it saved the petitioner’s life or not. This court cannot accept such a hollow approach.”
Justice Brar asserted that the court was not dealing with a matter of mere administrative reimbursement of a routine nature. It concerned the life and health of a person suffering from critical coronary artery disease. “The ground relied upon by the respondents to deny the petitioner their claim is that the coronary balloons used in the IVL are not the same used in normal and routine angioplasty, therefore IVL is not part of angioplasty package…,” he said.
“It seems that the respondents have chosen to adhere to the policy in its letter, while turning a blind eye to its spirit and true objective,” he added.
