State Consumer Disputes Redressal Commission
Lt. Col. Atma Singh (Retd vs The Managing Director, Fortis ... on 5 April, 2011
2nd Bench.
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB,
S.C.O. NO. 3009-10, SECTOR 22-D, CHANDIGARH.
Consumer Complaint No.3 of 2008
Date of institution: 22.01.2008.
Date of decision : 05.04.2011.
Lt. Col. Atma Singh (Retd.), resident of House No.44, Sector 10-A,
Chandigarh.
....Complainant
Versus
1. The Managing Director, Fortis Healthcare Limited, S.A.S. Nagar
(Mohali).
2. Dr. Ashok V. Chordiya, Medical Director, Fortis Healthcare Limited,
SAS Nagar (Mohali).
3. Dr. A.S. Bawa, Urology Surgeon, Fortis Healthcare Limited, SAS
Nagar (Mohali).
4. Dr. K.P. Singh, Endocrinologist Consultant, Fortis Healthcare
Limited, SAS Nagar (Mohali).
5. Dr. Rashmi Saluja, Incharge Special Intensive Care Unit, Fortis
Healthcare Limited, SAS Nagar (Mohali).
......Opposite parties
Consumer Complaint under Section 12 of the
Consumer Protection Act, 1986 as well as
application U/s 151 of the CPC for dismissal of
the complaint.
Before :-
Shri Inderjit Kaushik, Presiding Member.
Shri Baldev Singh Sekhon, Member.
Present :-
For the complainant : Shri H.S. Thiara, Advocate and Lt. Col. Atma Singh, complainant in person.
For the opposite parties: Shri Pavit Singh Mattewal, Advocate. INDERJIT KAUSHIK, PRESIDING MEMBER:
This complaint was originally decided by this Commission vide order dated 15.12.2009 and both the parties went in appeal and the Hon'ble National Commission vide order dated 26.08.2010 while setting aside the order dated 15.12.2009, has remanded back this complaint to Consumer Complaint No.3 of 2008. 2 this Commission to decide it afresh in accordance with law after affording reasonable opportunity to both the sides to make their submissions on the strength of existing pleadings, evidence and material.
2. Complaint u/s 12 of the Consumer Protection Act, 1986(hereafter called as "the Act") was flied by Lt. Col. Atma Singh (Retd.), complainant (hereinafter called as "the complainant") and the application u/s 151 of the CPC for dismissal of the complaint has been filed by the opposite parties. This order will dispose of both the complaint and the application.
3. The complainant has filed this complaint for claim of compensation and damages to the tune of Rs.50.00 lacs on account of deficiency in service in the nature of gross medical negligence on the part of the opposite parties.
4. It was submitted by the complainant that he was personally pursuing and monitoring the medical treatment of his wife and is well conversant with the facts and circumstances of the present case and is competent to file the present complaint.
5. On 17.05.2007, the wife of the complainant namely Smt. Raminder Atma Singh had gone to the Fortis Hospital, Mohali for pre- check up for her knee surgery and contacted Dr. K.P. Singh, Endocrinologist in his OPD and he prescribed some blood test. The wife of the complainant (in short, "the patient") returned home after giving blood sample but on the same day at about 2.30 P.M., the said doctor called her on telephone and asked her to return to the hospital immediately. She went back to the hospital and was told that her potassium level was high and a fresh blood sample was required to be taken. Dr. K.P. Singh told the patient that she had to be got admitted in the emergency as anything can happen and she was lured into admission by 5.00 p.m. on the same day and she was frightened. The potassium level was reduced and the patient Consumer Complaint No.3 of 2008. 3 could be treated as outdoor patient but Dr. K.P. Singh got conducted USG on 18.05.2007 to make money and USG test revealed dormant tumour on left kidney and CT scan was planned for 19th May, 2007.
6. On 19.05.2007, Dr. Hemant Hardikan, Urologist, met the patient and frightened her that the tumour was cancerous and cancer could spread in the body at any moment and the same had to be removed immediately. He insisted on immediate surgery without explaining post operative implications like bleeding, pain and affects on the other organs of the body. The patient was shocked and was not given any time to think. There was another alternative method of removing the kidney tumour like Radio Frequency Ablution whereby the kidney could be saved, but the same was not discussed. No biopsy was conducted to know whether the tumour was malignant nor any cancer expert was consulted.
7. On 23.05.2007, surgery was performed by Dr. A.S. Bawa, HOD Urologist and he also did not disclose any post operative complications like pain etc. to the patient. Dr. A.S. Bawa did not try to find out whether the said dormant tumour was malignant or not during the surgery. It was negligence on his part because had the tests shown to be benign, the left kidney should have been saved.
8. The patient was shifted to HDU after surgery and she was being given Clexane in the form of injections for about 5 days upto 27.5.2007. Clexane is trade name of Heparin which thins the blood, helps in flow and avoids clotting. This drug had the side affect like pain in the abdomen and back and it was not to be given to the patient who is bleeding. This aspect was completely ignored due to the negligence, as the surgery involved bleeding. As per the clinical case summary, no Heparin and Clexane was given which was actually given for five days, instead the doctors attributed it to epigastric pain or chest pain as shown in Consumer Complaint No.3 of 2008. 4 the summary. The Clexane doze was increased on 24th May to 28th May from 40 mg.
9. On 26.05.2007 the drain pipe was removed as soakage had increased as discussed as per the version of the surgeon Dr. A.S. Bawa. In fact, bleeding had not stopped and Clexane was given to the patient w.e.f. 23.05.2007 which had the side affect. Dr. A.S. Bawa discussed with Dr. K.P. Singh on 24.05.2007 that the patient may be throwing blood clots, as such, Clexane doze was increased without realizing its side effects which tentamounts to negligence. The patient was shifted to ward SPICU at the instance of the daughter of the complainant, as answered by Dr. A.S. Bawa which is unethical and carelessness which should have been done as per the condition of the patient and not due to the insistence of the daughter of the complainant. Whenever the complainant contacted Dr.A.S. Bawa regarding the condition of the patient, his reply was that his job was over and before recovery, how could he wash his hands and that is most unethical and negligent attitude on the part of Dr. A.S. Bawa.
10. On 27.05.2007 at about 8.30 P.M. the patient complained of pain in the abdomen and back due to the side effects of Clexane and the doctor gave her digene and on complaining again, the doctor gave her Pantocid pain killer as the patient was getting restless. The condition of the patient was deteriorating due to Clexane which was causing back pain and excess internal bleeding but the doctor could not correlate it and only thought of epigastric pain and she became pale at 5.00 A.M. on 28.05.2007. According to the case summary, the patient had pain in epigastrium after midnight, whereas nothing was mentioned regarding her pain from 9.30 P.M. to 2.15 A.M. Dr. A.S. Bawa in his reply stated that there are other qualified doctors to take care of the patient and he was not to examine the patient. He admitted that he was in regular touch, but he Consumer Complaint No.3 of 2008. 5 did not examine the patient on 27/28th May, 2007 which amounts to negligence on his part.
11. On 28.05.2007 at about 11.45 A.M. Dr. K.P. Singh examined the patient and found her in a very serious condition and advised to shift to SPICU. He also did not correlate the pain and the condition of the patient due to the side affect of Clexane. The blood of the patient was sent for examination and it was found that blood count HB has come down to 6 gms. at 12.00 noon on 28.05.2007 and inspite of this blood report, no treatment of blood transfusion was advised on 27th May and not before 5.12 P.M. on 28th May, 2007 which further amounts to negligence. The opposite parties have cooked upto the story in the case summary that blood transfusion was given on 28th May, 2007. Until 5.00 p.m., including SPICU incharge or Endocrinologist could correlate discomfort, pain in the abdomen of the patient. USG report had revealed that there was a fluid in the abdomen measuring 600 ml. on 28.5.2007 at 5.15 P.M. The U.S.G. should have been done at 6.00 A.M. on 28.5.2007 to save time and to find out the condition of the abdomen. Due to negligence of the doctors, more than 12 hours were lost to diagnose the disease. Dr. A.S. Bawa in his reply stated that there is no need for USG and there is no chance of infection enclosed abdomen by blood collection. He further stated that the patient had developed infection and because of the ineffective complications, the patient could not come out of it.
12. On 29.05.2007 in the morning, Dr. A.S.Bawa told the complainant that the condition of the patient was very critical and C.T. Scan was done at 11.00 A.M. and there was further delay upto 11.00 a.m.. In fact, second surgery should have been done immediately after USG report showing 600 ml. fluid in the abdomen but the doctors failed to examine the patient and to provide proper treatment within time and due to delay in providing medical facilities by the doctor, the blood pressure of the Consumer Complaint No.3 of 2008. 6 patient crashed and all vital organs like kidney, lungs and heart were damaged and the patient suffered pain as well as internal bleeding. At 11.00 A.M., Dr. Ashok Chordiya examined the patient and put her on ventilator and for the first time, the complainant was told that the patient is very serious and critical. All this happened due to the side effects of Clexane and complete negligence on the part of the opposite parties because there was delay in finding the HB count falling to 6 gms and no blood transfusion was given within time. The USG was also delayed for more than 12 hours and aspiration was done after 16 to 18 hours and no doctor discussed together the condition of the patient on 28.05.2007 to do second surgery. Had it been done on 28.05.2007, the patient could have been saved.
13. At 10.30 a.m. on 29th May, 2007, CT scan was done and as per the CT scan, the patient could not withstand the pain, restlessness and collapsed at 11.00 a.m. due to internal hoemorrhage. At 8.00 p.m., the patient was sinking and the team of the doctors got together and discussed her condition for the first time and it was concluded that second surgery be performed to remove all internal bleeding. Second surgery was done on 30.05.2007 at 3.00 a.m. by Dr. A.S. Bawa in the presence of Vascular Surgeon after a delay of 54 hours of the complaint made by the patient. One litre of blood and clots were removed which was sufficient to cause haemorrhage and damage to the vital parts of body of the patient.
14. The blood pressure of the patient crashed, the patient went into shock and could not withstand the trauma, leading to the patient to survive on ventilator, subsequent complications and infection etc., the patient died on 23.06.2007 at 10.15 a.m. in the hospital due to negligence of the opposite parties.
15. The patient had gone through second surgery on 30th May, 2007, but remained on ventilator and Dr. Ashok V. Chordiya gave them the Consumer Complaint No.3 of 2008. 7 hope of her survival. The patient was conscious but was unable to speak and express her condition due to ventilation with pipes in her mouth, mouth gagged with a bandage, pipe through her nose, centerline and monitors all over to check her blood pressure, pulse etc. The patient nodded her head to the questions and even wrote that she should be taken away because she would be killed in the hospital.
16. Dr. A.S. Bawa went on leave after 6th June, 2007 and there was no surgeon to take care of the patient. Vascular surgeon used to come to see her daily and see the blood range as the drain pipe was inserted once again after surgery. It took almost 16 days for the bleeding to stop and it was removed after that. After the first surgery, it was removed after three days which resulted in consequent deterioration of the patient due to negligence of the surgeon. With the drain pipe removed on 26th May, 2007, there was no way to assess internal bleeding taking place except doing US of abdomen, but this was not done in time. Dr. K.P. Singh went on leave from 4th June, 2007 to 9th June, 2007 and again on 12th June, 2007 and when the complainant asked him regarding the condition of the patient, he told that the surgeon has been changed, so complainant must face for his actions.
17. Dr. Vishal Mahajan also went on leave from 3rd June, 2007 to 15th June, 2007 and the patient was treated mostly by Dr. Ashok V. Chordiya and SPICU incharge Dr. Rashmi Saluja, who visited the patient for few minutes daily. The condition of the patient deteriorated due to carelessness, negligence and deficiency in service in diagnosing by giving Claxane with side effects and not conducting detailed examinations like USG, and the doctor surgeon who conducted the surgery not visiting, examining the patient after the surgery on 23.05.2007. X-ray revealed all along water in the lungs, as Pulmonologist was not consulted or called and reduced the swelling of patient in complete body due to edema. The Consumer Complaint No.3 of 2008. 8 Pulmonary consultant doctor and gastro consultant Dr. Chhabra was called on 22nd June, 2007 one day before death which was too late. They were unable to treat the patient. Dr. Ashok V. Chordiya went on leave on 21st June, 2007, two days before patient's death. Dr. Bela who took over from Dr. Ashok V. Chordiya in his absence, told the complainant on 22nd May, 2007 that the patient will not survive due to septicemia, as her TLC was very high.
18. The treatment given by the opposite parties after second surgery on 30th May, 2007 and keeping the patient on ventilator until her death on 23rd June, 2007, was to drag her life to make maximum mileage in terms of money, carrying out investigations, x-rays, diagnosis, USG, Physiotherapists visits etc. The patient could not express her last wish. She lay helpless. The patient was billed for Rs.7,85,714/-.
19. The opposite parties are likely to take shelter on the facts that the patient was obese, 75 years old, hypertensious and patient of thyroidism etc. All these aspects were known and she was cleared for surgery by Endocrinologist, Anaesthesist and Cardiac. Post operative care should have been taken with more responsibility and seriously by the concerned doctors and not as a routine and the main cause of her death was due to carelessness, casualness, irresponsibility, deficiency in service by doctors like surgeon Dr. A.S. Bawa, Dr. K.P. Singh, Endocrinologist and Dr. Rashmi Saluja, Incharge SPICU and those, who examined on 27th May and 28th May, 2007 and 29th May, 2007 and failed to diagnose the actual cause of patient pain in abdomen, back, restlessness, discomfort, which was due to internal bleeding collected within causing hemorrhage and damaging all vital parts of the patient namely right kidney, for renal failure, heart and lungs. Fortis Hospital has charged doctor's visit by Dr. B. Sharma on 23rd June, 2007 at 1.15 p.m., whereas, the patient died at 10.30 a.m. on 23rd May, 2007. The complainant claims an amount of Consumer Complaint No.3 of 2008. 9 liquidated damages to the extent of Rs.30.00 lacs on account o mental agony, sufferings and expenses incurred by the complainant from the opposite parties which were deficient in services, Rs.20.00 lacs for damages on account of physical and mental agony suffered by the deceased. The negligence on the part of the opposite parties resulted in vital injuries to the said patient which subsequently caused her death. Opposite party no.1 is the hospital which was required to provide infrastructure and manage its affairs to rule out such negligence and depth surgical operations. Opposite party no.3 is the surgeon, who carried out the surgery with sheer negligence of such nature which directly led to the fatal injuries and resultant death of the patient. It was prayed that Rs.50.00 (Fifty Lacs) be awarded as damages, cost of litigation.
20. In the reply filed on behalf of the opposite parties, the preliminary objections were taken that the complainant is not competent to file the present complaint. There was no negligence and deficiency in service, unfair trade practice, lack of professional ethics or standard by the opposite parties, instead the best possible treatment was provided despite the fact that the patient lost her life. Case of the complainant is based on conjectures and surmises and the complainant has filed the complaint which is frivolous and vexatious and abuse of process of law, as contemplated u/s 26 of the Act. The complainant has concealed material facts regarding medical condition of the patient. The complaint is bad for non-joinder of necessary parties. The complainant is a retired army person and has got himself registered under the Ex-Servicemen Contributory Health Scheme (ECHS) and under the scheme, Ex-servicemen are treated free of costs which in turn, gets paid from the army under the said scheme.
21. Wife of the complainant was admitted in the opposite party hospital and the entire medical expenses of the patient, were borne by the army under ECHS and the complainant was not required to pay anything. Consumer Complaint No.3 of 2008. 10 The complainant has made a false representation by averring in para no.21 that he incurred expenditure to the tune of Rs.30.00 lacs and claimed damages. The complainant was required to pay Rs.176/- which were in respect of beverage and telephone charges, including the bags which were used by the relatives of the patient, who visited the hospital. The complainant has also concealed the fact that Army Command Hospital had conducted its own inquiry(medical) into the treatment given by the opposite parties and after the inquiry, it absolutely absolved the opposite party hospital from any allegation of negligence and upheld the line of treatment and procedure adopted by the opposite party hospital. After conducting the inquiry and on the basis of case summary, the Command Hospital Dr. Col. S.K. Tripathi after going through the entire file including of the emergency admission intimation, referral form, approvals, case summary, death clinical summary, answer to questionnaire, study report, bills, mortality data of the last two years of Fortis Hospital, submitted the report and commented as follows:-
"The patient was an old case of:-
a) Hypothyroidism b) Hypertension c) Morbid Obesity d) Cholelithiasis
She was prepared for surgery, radical nephrectomy on 23rd May, 2007. Necessary documentation required for hospitalization, treatment and surgery, was found correct. During post operative period, patient developed DIC, Sepsis, Renal failure and ARDS. Ultimately, patient died of sudden cardiac arrest on 23rd June, 2007 inspite of all ventilator and ionotropic support along with higher antibiotics haemodialysis, transfusion of blood, blood components. Apparently, the patient did not recover from the complications of the major surgery an elderly, obese patient with Consumer Complaint No.3 of 2008. 11 hypothyroidism, cancer, hypertension, Dyselectrolytemia. The medical officer who is author of this report and ECHS are the necessary parties. The complainant has not paid anything for medical service rendered and is not a 'consumer' under the Act. The Command Hospital has found the treatment and surgery done to be correct and without any further action, sent the case file back to the complainant with a copy to the Western Command. Therefore, the complainant has no cause of action against the opposite parties.
22. It was further submitted that Mrs. Raminder Atma Singh was 75 years old patient UHID number 126312. She was a known patient of hypertension and had gone for pre-operative check up from Dr. K.P. Singh for her knee replacement surgery and he advised various tests. The report of the test revealed 'Hyperkalemia' which means that the potassium level was abnormally high. High level of potassium, 'Hyperkalemia' is important and serious indicator and requires urgent treatment. The patient was advised emergency admission. The patient was taken for ultrasound and CT scan which revealed effusion (tumour) in her left kidney which was indicative of renal cell carcinoma. Thereafter, urological consultation was done and the patient was advised removal of kidney tumour. Biopsy in such cases is not recommended due to risk of haemorrhage or spread of tumour cells and only the CT scan is recommended in such cases being the conclusive tests. In the instant case, CT scan was a clear indicator of cancerous growth and clear indication for surgical removal.
23. The surgery was conducted on 23rd May, 2007. Since, the patient was suffering from cancer of the kidney, the operation for removal of cancerous growth and the cancer affected kidney was a high risk operation which was conducted successfully. High risk informed consent form is attached. Radio frequency is not for big tumour, it is still on experimental basis and for small tumours. This facility is currently not Consumer Complaint No.3 of 2008. 12 available in the country and the literature shows that radio frequency is not used in tumour bigger than 3 cms.
24. After the surgery, the patient was kept in SPICU. She was not showing signs of recovery and was eating well. The doctors as a team were looking after the patient. Once her pain killer, central line, catheter and drain was removed as the drainage was nill, patient was shifted to the ward after a collective decision of the doctors and at that stage, the reports of the patient were not suggestive of bleeding, sepsis or any heart problem. A team comprising of senior consultants of internal medicine, urologist, endocrinologist, SPICU incharge were managing the patient constantly and the patient stabilized initially, but thereafter she developed low blood pressure due to which an ultra sound and CT scan were immediately conducted which revealed a collection of fluid in the abdomen. The abdominal fluid was aspirated. The patient was suffering from pain, distension with hypertension. The doctors found that there was a collection of blood from the raw surface. In other words, oozing bleeding was present. The oozing of blood in the abdomen was not a cause of claxane medicine, but it is a usual side effect of surgery from raw area from which the kidney carcinoma has been removed surgically. The patient initially responded well to the antibiotic cover. Due to recurrence of the discomfit and to surgically arrest the problem of fluid collection, an exploratory laprotomy was done on 30th of May, 2007 which was a serious surgery and prior to that, a detailed consideration of the patient's condition was conducted. A death on table consent form was also signed by the relatives of the patient. The re-exploration was done with the object to supplement the use of antibiotics in order to remove the infection and thereby improving the potentiality of antibiotic action and about 600 ml of clotted blood was taken out and a drain was inserted.
Consumer Complaint No.3 of 2008. 13
25. The patient continued to have low blood pressure, diagnosis of sepsis was confirmed at this stage. Considering high TLC, DLC, D- Dimer was raised, DVT Heparine was also started, blood, platelets and FFPs were transfused. D-Dimer test was confirmatory diagnosis of sepsis. The patient was put on a medicine cover. Her urine output had decreased and she required ventilatory support. In view of the increased creatinine levels and fluid over load, the nephrologists was called and the patient was put on Lasix infusion since her output was less, nephrology consultation was done and the patient was put on dialysis on 4th June, 2007. Then her creatinine level decreased. The patient having sustained a multi organ deterioration and overwhelming sepsis was unable to respond to treatment and support. The patient continued to deteriorate and was ventilator dependent. Multiple transfusions were given, for her hypertension, inotrops were also given. Despite repeated dialysis, the patient had a sudden cardio respiratory arrest on 23rd June, 2007, but despite best efforts of the doctors and supportive measures of the world class standards, the patient died.
26. On merits, similar pleas were repeated. It was admitted that Dr. Hemant Hardikar, Urologist met the patient on 19th May, 2007 and told her that the said tumour was cancerous which could spread at any moment and because of this, he recommended that it should be removed along with left kidney immediately. It is evident from the report of USG/CT scan/Bed Report that there was actually a tumour of left kidney and it was cancerous which required immediate operation for removal. The standard method of treatment was adopted. It was also admitted that the surgery was performed by Dr. A.S. Bawa, HOD Urologist on 23.05.2007. The patient was shifted to SPICU after the surgery. On 28.06.2008, patient complained of epigastric pain and burning sensation in the abdomen. Consumer Complaint No.3 of 2008. 14 Earlier, she was given pentocid and Mucaine gel which relieved the epigastric pain.
27. The clexane drug was correctly administered to the patient at all times as a curative intent. The drug clexane was administered to the patient as per standard protocol in such patients and given following doses in correct manner:-
Date Doses
21/05 0.4 ml subcutaneous once daily.
22/05 0.4 ml subcutaneous once daily
23/05 0.6 ml subcutaneous once daily
24/05 0.6 ml subcutaneous once daily
25/05 0.8 ml subcutaneous once daily
26/05 0.8 ml subcutaneous once daily
27/05 0.8 ml subcutaneous once daily
28/05 0.8 ml subcutaneous once daily
The drug Clexane was discontinued after 28.05.2007.
28. The drug Clexane was given as prophylactic for preventing DVT and pulmonary embolism. Both of which are dreaded complications in such patients. This drug was administered in prophylactic doses as a mandatory and indicated preventive measure against blood clot since the patient had undergone major surgery and was bed-ridden. Since the patient was immobile, suffering cancer, morbidly obese and above 70 years of age, was predictably predisposed for both PE and DVT. Clexane was given to the patient with diligent monitoring and care as a curative and preventive measure to prevent pulmonary thrombo embolism and deep vein thrombosis. By giving prophylactic doses, the doctors sought to achieve a balance between the risk of DE and VT and the best possible Consumer Complaint No.3 of 2008. 15 means to redress the same, having regard to the patient's condition of immobility and morbid obesity etc.
29. The drain was removed on 26th May because there was minimal output or bleeding which further substantiates the fact that the patient was given correct treatment. The patient was treated by a team of doctors and the decision to shift the patient, was taken by the team of the doctors after mutual consultations. Dr. Bawa was telephonically in touch with the team of doctors handling the patient at all times in the post operative care period and was personally monitoring the case. Dr. K.P. Singh examined the patient on 28th May, 2007 at 11.40 a.m. and he ordered to shift her to SPICU and visited the patient on 28th May on regular calls. There was an overwhelming sepsis in the patient. The patient was shifted to SPICU because of pain and restlessness for further evaluation and closer monitoring. The blood of the patient was sent for examination and as per the blood report, Hemoglobin was 6 gms. on 28.05.2007. USG report dated 28.05.2007 revealed 600 ml. of fluid in the left renal fossa which was due to oozing from surgical site. More than 30 units of blood and blood components were transfused to the patient. Blood transfusion took place on 20/05, 23/05, 28/05, 29/05, 30/05 and 05.06.2007. In a multi speciality hospital like Fortis, different departments have been carved out which are under the charge of competent and highly qualified doctors. A surgeon is required to perform an operation diligently and to the best of his abilities which the surgeon Dr. K.P. Singh did and remained in constant touch with the doctors who were taking care of the patient as a collective responsibility. The doctors incharge were competent to take care of the patients in the ward and they took expert advice from Surgeon Dr. A.S. Bawa. Dr. Bawa had explained to the relatives of the patient that he is an expert in the field of surgery and he had conducted the operations Consumer Complaint No.3 of 2008. 16 successfully and in the present case, after the surgery, he visited the patient regularly and monitored her closely.
30. The patient had increased heart rate, increased respiratory rate and breathlessness. Blood pressure was 120 at 10.00 a.m. and 110 at 1.00 a.m. and did not collapse at 11.00 a.m. and was stable. There was no delay whatsoever in performing the second operation. The object of second surgery was a life saving measure. The doctors did their best and tried to save the patient and did not commit any negligence. The complainant has made baseless allegations which are highly objectionable.
31. It was admitted that opposite party no.3 was on leave for some days post 6th June, 2010, but there was a Vascular Surgeon who came to see the patient daily and adopted the procedure to drain out the blood. The drain pipe was inserted to drain out any collected fluid after re- exploration from raw area in the retroperitoneum. Dr. K.P. Singh went on leave from 4th June, 2007 to 9th June, 2007 and thereafter on 12th June, 2007. The respondent hospital has a world class infrastructure and anti- infection protocols and special care is taken with regard to the same. Complainant himself admitted that the condition of the patient deteriorated due to infection which contradicts his earlier claim that Clexane was the main cause of her deterioration. The condition of lungs revealed through x- ray showed a minimal plural effusion on 2nd June and the patient at this stage was showing the sign of improvement. It was admitted that that the total bill was Rs.7,85,714/- which was due to different procedures and operations conducted on the patient primarily to save the patient and the bill was submitted to ECHS authorities for payment. Complainant did not make payment of this bill. There was no negligence or unfair trade practice on the part of the opposite parties. All other allegations were denied being Consumer Complaint No.3 of 2008. 17 wrong and incorrect and it was prayed that the complaint may be dismissed.
32. Replication was filed by the complainant in which, he re- iterated the pleas taken in the complaint and denied those of the written statement.
33. Parties adduced evidence in support of their respective contentions by way of affidavits and documents.
34. Both the parties have filed written arguments as well as argued verbally. We have gone through the entire record minutely.
35. The complainant himself argued as per the pleadings in the complaint and replication and in the written arguments, it was submitted that earlier, his complaint was accepted and he was awarded the compensation as well as litigation expenses and he filed the appeal for enhancement of the compensation as well as on the points which were inadvertently missed and the Hon'ble National Commission remanded the case.
36. On 17.05.2010, patient Raminder Atma Singh went to Dr. K.P. Singh of Fortis Hospital for check-up of knee surgery and blood sample was taken and she was normal. A call was received from Dr. K.P. Singh to immediately come to the hospital and on going there, Dr. K.P. Singh told that the potassium level was very high and she had to be admitted in the emergency as anything can happen. It shocked the patient and the doctor was told that she will get a reference from ECHS for admission and come next day and on her request, second sample was taken and the potassium level came down from 8 to 7, but she was admitted and was not allowed to move. Without conducting any investigation like ultrasound/CT scan, it was told that she was suffering from cancer (tumor on left kidney). The admission of the patient was on unethical grounds and unfair trade practice.
Consumer Complaint No.3 of 2008. 18
37. On 18th May, ultrasound scan was done and the cancer was detected, but the request for Oncologist and biopsy was denied and the same was done after five days. On 28th May after the operation, Dr. Hardikr, Urologist explained that the operation is simple and the other kidney will take the load, but never disclosed about the post operation complications.
38. Dr. Bawa did not visit personally or examine the patient during post operative period particularly on 27th, 28th and 29th May, when the condition of the patient was deteriorating. He visited only on 4th, 5th and 6th June, when the patient was on ventilator support and then he went on leave on 6th June itself. It is negligence on his part. Dr. K.P. Singh visited before the operation but after the operation, he visited on call on 28th May and 29th May and he also proceeded on leave on 9th June. His assistant was also on leave. Dr. B. Sharma charged the patient for his visit at 1.12 p.m. on 23rd June, two and a half hours after the death and this amounts to cheating and falsely charging the patient.
39. Drug Clexane was given in anticipation and continued upto 28th May and the dose was increased to 80 mgs twice daily and it was suddenly stopped on 29th May because it had the side effects of bleeding. The surgeon failed to reduce the dose as the correct dose was 20 mgs daily. The side effects of bleedings or Haemorrhage should have been investigated, but that was not done. Due to high dose of Clexane, the patient started bleeding and the same caused Haemorrhage, but the surgeon did not visit which amounts to great negligence. Re-exploration was done at 3.00 a.m. on 30th May after the delay of 33 hours and the drain was re-inserted, as earlier it was prematurely removed on 26th May and the blood kept on collecting internally which further amounts to gross negligence.
Consumer Complaint No.3 of 2008. 19
40. On 28th May at 5.00 p.m., ultrasound was conducted and it was found that 600 ml of fluid/blood had collected in the abdomen and the same was not removed on 28th May and the condition of the patient became bad to worse and the patient was aspirated repeatedly three times at 9.30 p.m. on 28th May and 300 ml fluid was removed. Likewise, again 250 ml fluid was removed and on 29th May, again 200 ml fluid was removed, but it was not sent for investigation. The repeated aspiration caused infection. No consent form was taken for the said aspirations. The infection could have been avoided, if re-exploration was done before the aspiration on 30th May after 5.00 p.m. and no explanation is coming forward as to how the patient got infection.
41. On 26th May, the drain was removed prematurely and the correct procedure to remove the same was not followed and that led to bleeding inside due to which, maximum damage was done and the patient got infection and became dialysis dependant and died on 23rd June due to septicemia infection.
42. Re-exploration was done after 33 hours' delay and the figure of one litre was reduced to 600 ml and that makes the surgeon untrustworthy. The treatment was delayed despite the complaint made on 27th and 28th May night. Without investigating the real cause, the treatment for apigastric pain was given and the investigation reports were also delayed which further delayed the blood transfusion and that further amounts to negligence on the part of the doctors. Dr. K.P. Singh on finding the patient serious, ordered her to be shifted to SPICU immediately, but again it took three hours to shift the patient and the condition of the patient further deteriorated.
43. ENT specialist Dr. Abrol conducted trachestomy i.e. shifting of pipe from the mouth to neck of the ventilator on 7th June, whereas it should have been done on 28th May and the patient remained gagged till 7th June. Consumer Complaint No.3 of 2008. 20 Dr. (Col.) Tripathi of ECHS who is stated to have conducted the inquiry, was not competent to make any comments. Fresh evidence brought by the opposite parties regarding the use of Clexane as curative measure, is not admissible. Normal process of healing due to clotting was denied to the patient and the side effects of the Clexane were not noticed and excess dose was given. The patient suffered tremendously and died a treacherous death and all this happened due to the callousness and negligence on the part of the doctors and particularly the surgeon, who did not care to personally examine or visit the patient during post-operative period and was only in touch with doctors handling the case.
(Complainant has repeated the facts again and again and the relevant part of the arguments is discussed as mentioned above).
44. In the written arguments filed on behalf of the opposite parties, it was submitted that Mrs. Raminder Atma Singh was a known patient of hypertension and she came for pre-operative check-up for her knee replacement surgery. Dr. K.P. Singh advised for various tests and potassium level was found abnormally high which is known as 'Hyperkalemia' and it can cause cardiac arrest etc., if not attended to and for that, she was immediately admitted in the emergency. CT scan report revealed tumor in her left kidney and after urology consultation, patient was advised left radical nephrectomy i.e. removal of kidney tumor. Biopsy in such case is not recommended due to risk of haemorrhage or spread of tumor cells. The only established practice was removal of the kidney through surgery. The patient was suffering from cancer and the removal of cancer growth and the cancer affected kidney was a high risk operation which was conducted successfully.
45. After the operation, the patient was kept in SPICU and she was showing the signs of recovery and was eating well and the team of doctors was looking after her and after the removal of the drain, catheter Consumer Complaint No.3 of 2008. 21 etc., she was shifted to the ward. In the ward, she complained pain in the abdomen and back and she was again shifted to the SPICU for further investigation. In the SPICU, the investigation was thoroughly conducted. The team comprising of senior consultants of internal medicine, urologists, endocrinologist was managing the patient. Initially, the patient stabilized but later on, developed low blood pressure and CT scan revealed that there was a collection of fluid in the abdomen and the same was aspirated. At the site of the operation, oozing bleeding (wound sockage) was present which was a usual side effect of surgery from the raw area and it was not because of Clexane medicine. Due to the recurrence of the oozing and to surgically arrest the problem of fluid collection, exploratory laprotomy was done on 30th May, 2007. By re-exploration, about 600 ml of clotted blood was taken out and the drain was inserted. The patient suffered from low blood pressure and the blood transfusion was done and the treatment of infection was also started. In view of the increased creatinine levels and the fluid overload, the Nephrologist was called in. The patient was put on Lasix infusion as her output was less and a dialysis was also done and after the dialysis on 4th June, 2007, the creatinine level decreased. The patient having sustained multiple organ deterioration and overwhelming sepsis, was not responding to the treatment and the support and she became ventilator dependent. Multiple transfusions were given and despite the repeated dialysis, patient had a sudden cardiac arrest on 23rd June, 2007 and could not be revived despite best efforts.
46. Clexane drug was correctly administered as per the standard protocol and it was discontinued after 28.05.2007. The said drug was given for preventing DVT and Pulmonry embolism with a preventive and curative intent. As per the literature, the dose of Clexane to be given to Urology (general surgery patients), is 1 milligram per kilogram twice daily. The patient was 90 kgs of the weight and maximum dose was 90 ml twice daily, Consumer Complaint No.3 of 2008. 22 whereas the patient was given 80 ml twice daily from 25th May to 28th May. The renal function was not impaired. The patient being immobile, suffering cancer, morbidly obese and above 70 years of age, was predisposed for both PE and DVT.
47. For removal of the drain, the standard protocol is that when the output is less than 25 ml in 24 hours, then the documented practice is to remove the same, as was done in the present case on 26.05.2007. The best possible treatment was provided. 24 hours attendance of doctors and nurses is available in the ICU and the respondent-Fortis Hospital is having one of the best available ICU in the whole of the Northern India. The consent forms of the patient were taken and the best possible treatment was provided to the wife of the complainant. A team of the doctors looked after the patient, who were specialist in their respective fields. The operating surgeon and the doctors taking care of the patient in the post operative period, were in touch with each other and Dr. Bawa is an expert in the field of surgery which was conducted by him successfully and he visited and monitored the patient even after the surgery. Dr. Rashmi Saluja was the incharge and leading ICU team to look after the patient at all times during her post operative period at the hospital. All the decisions were taken collectively and there was no delay. The patient was not left unattended. The post operative complications are approximately 20% as per the literature and sepsis is the common complication encountered in the post operative period.
48. The complainant has concealed the fact that the Army Command Hospital had conducted its own inquiry (Medical) into the treatment given by the opposite parties and absolved the opposite party hospital from all allegations of negligence and upheld the line of treatment and the procedure adopted by the respondent. Dr. (Col.) S.K. Tripathi conducted inquiry and submitted the report.
Consumer Complaint No.3 of 2008. 23
49. The complainant has suppressed the material facts and the opposite parties moved an application for dismissal of the complaint and the Hon'ble National Commission recorded that there was a consent document prior to 23rd May, 2007 on record and remanded the matter back and only the finding against the respondent in earlier order, was that there was no consent taken prior to the operation on 23rd May, 2007. The complainant has made an attempt to place on record fresh pleadings, but as per the order of the Hon'ble National Commission, no new material can be taken on record. There was no negligence on the part of the respondent hospital and others and the Hon'ble Supreme Court has defined the negligence in recent judgments and the complaint is liable to the dismissed and prayed that the complaint may be dismissed.
50. We have considered the oral as well as written submissions filed by the learned counsel for both the parties and have perused the entire record minutely.
51. The complainant has produced original complaint Ex.C1, billing details Ex.C2, Case summary Ex.C3, Clinical summary Ex.C4, reply of Dr. A.S. Bawa Ex.C5, affidavit of Dr. V.K. Kandalkar, M.S. Ex.C6; laboratory report Ex.C7 (Ex.R18); pharmacy inphorma clexane dozing for special patient groups Ex.C8; reply of the opposite parties no.1 to 5 Ex.C9; consents form Ex.C10 (Ex.R8); literature regarding complications after radical nephrectomy Ex.C11 and description of Clexane (Enoxaparin) Ex.C12 (Ex.R14).
52. On the other hand, the opposite parties have placed on the file, affidavit of Dr. A.S. Bawa as Ex.R1; additional affidavit of Dr. A.S. Bawa Ex.R2, Expert evidence Ex.R3; definition/complication related with hyperkalemia including cardiac arrest Ex.R4; definition of radical nephrectomy Ex.R5; literature of CT scan and risk of fine needle aspiration Ex.R6; literature regarding solid renal mass standard treatment surgical Consumer Complaint No.3 of 2008. 24 removal Ex.R7, Consent forms Ex.R8 (Ex.C10). suppressed consent form Ex.R9; literature with regard to radio frequency ablation(RFA) of Renal Masses Ex.R10, CT scan report dated 18.05.2007 Ex.R11; complications of radical nephrectomy Ex.R12; literature regarding infection complications Ex.R13; literature defining Clexane Ex.R14(Ex.C12); literature regarding Clexane to prevent DVT Ex.R15; literature showing dosage of Clexane Ex.R16; list of 11 doctors who were looking after the patient Ex.R17; Laboratory report showing renal cell carcinoma Ex.R18(Ex.C7), review application Ex.R19, copy of order passed in review application Ex.R20, copy of the order passed by the Hon'ble National Commission Ex.R21 and replies of Dr. Bawa as Ex.R22.
53. The complainant in his arguments attributed the unfair trade practice to Dr. K.P. Singh for the reasons that the said doctor did not allow the patient Mrs. Raminder Atma Singh, to take another opinion or to get the matter referred through ECHS as the complainant is an ex-serviceman and admitted her on the same day. The opposite parties have taken the plea that the blood sample reports suggested that the potassium level was very high and for that reason, she was admitted immediately.
54. When the potassium level is high, the medical term for the same is Hyperkalemia and the literature qua Hyperkalemia is Ex.R4 wherein, the Hyperkalemia is defined as under:-
"Hyperkalemia is a condition caused by higher than normal levels of potassium in the bloodstream".
55. Ex.R4 further provides about the possible complications of Hyperkalemia and the same are:-
(i) Arrhythmias (ii) Cardiac Arrest
(iii) Changes in nerve and muscle (neuromuscular) control. Consumer Complaint No.3 of 2008. 25 Under the head "Treatment", it is mentioned as follows:-
"Cardiac arrest (absent heartbeat) may occur at any time during the treatment of hyperkalemia. Hospitalization and close monitoring are required".
56. Thus, from the above medical literature, it is clear that the Hyperkalemia is very dangerous condition which can cause cardiac arrest or other serious problems and the immediate treatment is hospitalization and close monitoring is required. The same was done by Dr. K.P. Singh and his advice was as per the literature and he suggested for immediate hospitalization of the patient for monitoring. As such, no mal-practice or negligence or unfair trade practice can be attributed to him, as he advised hospitalization which was in the interest of the patient and the immediate monitoring was required.
57. The next contention raised by the complainant was that without conducting any investigation like ultrasound/CT scan, it was told that she was suffering from cancer. It was further contended that on 18th May, 2007, ultrasound scan was done and the cancer was detected, but the request for Oncologist and Biopsy was denied. Admittedly, CT scan was conducted on 18.05.2007 and it revealed a lesion (Tumor) in her left kidney and renal cell carcinoma was indicated. As per the literature "Urology" Ex.R6:-
"Renal CT scan remains the single important radiographic test for delineating the nature of renal mass".
58. Regarding Biopsy, literature Ex.R7 Radical Nephrectomy provides as under:-
"The role of percutaneous biopsy or needle aspiration in differentiating an indeterminate renal mass remains controversial, and the absence of malignant cells on biopsy does not rule out the possibility of a neoplasm. In addition, there is the potential for seeding the biopsy tract with cancer. For these reasons, Consumer Complaint No.3 of 2008. 26 percutaneous renal biopsy for the purpose of diagnosis should be used only in selected cases".
59. Thus, from the above, it is clear that in the CT scan report, it was clear that there was tumor in the left kidney of the patient which was indicative of renal cell carcinoma and the biopsy at that stage was not required to be conducted, as there was potential for seeding the biopsy tract with cancer. The biopsy is not required in all the cases. Therefore, the line of treatment adopted by the respondent hospital was in accordance with the medical literature as well as the latest techniques and there is no negligence or unfair trade practice on the part of the opposite parties.
60. The surgery was conducted on 23rd May, 2007 and the cancerous growth was removed and it was a high risk operation, but the same was conducted successfully. The contention raised by the complainant that post-operation complications were not explained and the doctor who conducted the surgery did not visit the patient or Dr. K.P. Singh did not visit the patient, is without any basis, because the patient was kept in SPICU and the doctors as mentioned in the list by the complainant himself as well as in the list Ex.R17, were looking after the patient as a team and the complainant has no reason to blame the doctors, because post-operation care was taken by the experienced and well qualified doctors. It is not expected that as per the asking of the complainant or as per his whims and wishes, the post-operation care will be taken by a particular doctor or doctors. It is for the opposite party hospital to look into and to put on duty the qualified doctors because for the hospital, the important matter is not to carry out the operation only, but equally important is the post-operation care and the list of doctors as provided by the complainant himself as well as Ex.R17 shows that the qualified doctors were taking care of the patients in the ICU and in the wards. Even Dr. K.P. Singh, Dr. Bawa also visited the patient. The complainant blamed the Consumer Complaint No.3 of 2008. 27 doctors that they went on leave without informing the patient or the complainant, but in our opinion the leave management of doctors is the responsibility of the opposite party hospital and not of the patients or the complainant.
61. The next argument advanced and submitted in the written arguments, is regarding giving of drug Clexane. As per the literature Ex.C12 relied upon by the complainant, "Clexane (Enoxaparin) is used for preventing blood clots and particularly following general surgery and not to be used in active major bleeding and the side effects are major bleeding (haemorrhage) for example, in the abdomen or inside the skull".
62. The complainant laid much stress that the said medicine was not given correctly which was 20 milligrams daily, whereas the dose given was 80 milligrams twice a day and that resulted in bleeding and the re- exploration was not done immediately. The opposite parties have also placed on file the similar literature Ex.R14 and Ex.R16 which provides the dose of Clexane as per which, the dose of Clexane to be given to urology patients is 1 (one) milligram per kg. weight twice daily and the weight of the patient was 75 kgs. as per the record and giving of 160 milligrams of the drug Clexane cannot be said to be on the higher side. The complainant has taken the figure of 20 milligrams as correct dose, but there is no medical literature to support this contention and the bleeding cannot be said to be due to the administration of drug Clexane, but it is the complication after the operation. The complainant has also relied upon Ex.C8 and under the head "Severe Renal Impairment", the standard dosing is 1 (one) milligram per kg. twice daily.
63. The next contention of the complainant is that once it was found that the patient is bleeding, the aspiration was not done immediately. As per the complainant himself, on 28th May, 2007 the dose of drug Clexane was increased to 80 milligrams twice daily and on 28th May itself Consumer Complaint No.3 of 2008. 28 at 5.00 p.m., the ultrasound was conducted and the fluid/blood was not removed immediately. This contention is not tenable because at 9.30 p.m. on 28th May itself, 300 milligrams of fluid was removed and on next day also, the remaining fluid was removed. The complainant contended that due to delay in removal of fluid, infection was caused. This contention raised by the complainant is also not tenable because as per the medical literature Ex.C11 relied upon by the complainant himself, the infection is the common complication after the surgery and in the said literature, it is provided as under:-
"Infection is a common complication encountered in the post- operative period. Superficial wound infections are best managed by removal of skin sutures or staples to allow drainage. Deeper infections must be treated by the establishment of adequate drainage and the administration of appropriate antibiotics when there are systemic manifestations of the infection".
64. So far as the removal of drain is concerned, the same was removed as per the standard protocol and on 26th May, 2007, the output was less than 25 milliliters in 24 hours and as per the literature and the practice, the same was removed. Thus, the contention of the complainant that it was prematurely removed, is not supported by any material, medical literature or any expert evidence and, as such, is without any force.
65. The next contention that the re-exploration was done after 33 hours' delay and the figure of one litre was reduced to 600 ml, again is devoid of any force because the collective decision has to be taken by the doctors and the patient was unfit for surgery/anesthesia prior to the re- exploration and re-exploration at the cost of the life of the patient could not be undertaken. The best treatment was given and the patient was shifted to ICU again and when the patient was being looked after and was under
the care of qualified doctors, then mere shifting of the patient to ICU with a normal procedural delay, cannot be considered to be negligence when the Consumer Complaint No.3 of 2008. 29 patient was under the constant care and management of the opposite parties.
66. The treatment cannot be given as per the wishes of the complainant and his argument that ENT Specialist Dr. Abrol conducted trachestomy (shifting of pipe from mouth to neck of the ventilator) on 7th June whereas it should have been done on 28th May, cannot be said to be any unfair trade practice or negligence and the complainant is not the expert to say that the pipe should have been shifted on 28th May itself as the complainant is a laymen. There is no evidence or any material on record to prove that the shifting of the pipe from mouth to neck of the ventilator should have been done on 28th May, as suggested.
67. The complainant himself made a complaint to the Army Command Hospital, Chandimandir and Dr. S.K. Tripathi, who went through the case summary, CT scan as well as other documents and mentioned in brief about the post-operative care taken. However, he mentioned that so far as the management of the patient in the multi-disciplinary fields is concerned, he is not competent to comment but he has nowhere suggested that the line of treatment adopted by the opposite parties, was incorrect and all together contrary to the medical standards and latest techniques.
68. The complainant has not refuted or rebutted in any manner that the entire medical expenditure of patient Mrs. Raminder Atma Singh, was borne by ECHS authorities and only Rs.176/- were spent by the complainant from his pocket. Thus, it amounts to taking free treatment as the medical expenditure of more than Rs.7.00 lacs was borne by the ECHS authorities and the payment was made to the opposite party hospital by the said authority for the treatment of the said patient.
69. The complainant himself has placed on file the consent forms Ex.C10 (colly) and the opposite parties have also placed on file the Consumer Complaint No.3 of 2008. 30 consent forms Ex.R8 (colly) and Ex.R9 (colly). Perusal of all these consent forms proves that for performing any surgery, blood transfusion, anesthesia etc., the consent of the patient was taken on every occasion which was witnessed by the complainant himself and another witness and as an attendant, the complainant was present in the respondent hospital throughout and it was admitted during the arguments that the consent of the patient was obtained as and when it was required and nothing was done without taking prior consent.
70. In case "V. Kishan Rao Vs Nikhil Super Speciality Hospital", (2010) 5-Supreme Court Cases-513(SC), Hon'ble Supreme Court discussed the relevant judgments from the years 1865 to 2009 and observed in Para Nos.50 & 51 as follows:-
50. In a case where negligence is evident, the principle of re-ipsa-
loquitur operates and the complainant does not have to prove anything as the thing (res) proves itself. In such a case, it is for the respondent to prove that he has taken care and done his duty to repel the charge of negligence.
51. If the general directions in para 106 in D'Souza are to be followed then the doctrine of res-ipsa-loquitur which is applied in cases of medical negligence by this Court and also by courts in England, would be redundant".
71. In case "Raj Bhalla Vs Vimhans" IV (2009) CPJ-182 (NC), Hon'ble National Commission observed in Para Nos.14 & 15 as follows:-
14. The medical text books clearly indicate that those are problems arising out of old age, diabetes and hypertension which the complainant was having. It is only a corrective advance surgery that has been undertaken by the opposite party as per the guidelines of the medical text books. The opposite party has done whatever they could do with the knowledge of the problems that she is having and considering that she suffers from diabetes and hypertension, they had controlled these parameters at the time of operation. The age factor was already the prime consideration throughout her treatment, which cannot be followed by any medical standard that Consumer Complaint No.3 of 2008. 31 they have not done correct surgery or corrective treatment when she had infection.
15. The complainant has not filed any expert evidence from any doctor or medical text reference to prove negligence against the opposite party. She could have at least got some letter or a noting from her own family doctor, Dr. Ashok Khurana to support her case that she has suffered due to negligence of opposite party. Since there is no medical negligence or deficiency in service on the part of the opposite party, the question of compensation does not arise".
72. In view of above discussion, it is proved that the opposite parties have taken due care and followed the correct line of treatment and there was no negligence or unfair trade practice on their part. All the doctors of the opposite party hospital are qualified and experienced doctors and except the allegation against them of unfair trade practice or following unethical ways, there is nothing on record to prove that they were negligent in any manner in treating the patient. The complainant has failed to prove any medical negligence on their part or the unfair trade practice or that they did not opt for the correct treatment. Entire expenses on the treatment of the patient Mrs. Raminder Atma Singh were borne under the ECHS Scheme except Rs.176/- which amount to taking of free treatment.
73. In view of the detailed discussion, there is no merit in the present complaint and the same is dismissed and the application filed by the opposite parties is accordingly disposed of. No order as to costs.
74. The arguments were heard in this case on 22.03.2011 and the order was reserved. Now, the order be communicated to the parties. .
(Inderjit Kaushik) Presiding Member (Baldev Singh Sekhon) Member April 05, 2011.
(Gurmeet Singh)