State Consumer Disputes Redressal Commission
Silver Oaks Hospital, vs S. Mohinder Pratap Singh, on 7 March, 2014
2nd Additional Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB
DAKSHIN MARG, SECTOR 37-A, CHANDIGARH
First Appeal No. 62 of 2011
Date of institution: 13.1.2011
Date of Decision: 7.3.2014
1. Silver Oaks Hospital, Phase IX, Sector 63, S.A.S. Nagar, Mohali
through its Managing Director-cum-Chairman.
2. Dr. Akhil Bhargava, Silver Oaks Hospital, MBBS, MD, Medicine.
3. Dr. Rahul Gupta, Silver Oaks Hospital, MBBS, MD, Medicine (3
years experience in Hepatology from PGIMER).
4. Dr. Parmod, Silver Oaks Hospital, MBBS, MD, Psychiatry.
.....Appellants/Opposite Parties
Versus
S. Mohinder Pratap Singh, M.A.LL.B S/o S. Darshan Singh, r/o House No.
1282, Sector 15-B, Chandigarh.
.....Respondent/Complainant
Argued By:-
For the appellants : Sh. G.S. Ahluwalia, Advocate
For the respondent : Sh. Deepak Aggarwal, Advocate
First Appeal against the order dated
10.12.2010 passed by the District Consumer
Disputes Redressal Forum, SAS Nagar
(Mohali).
Quorum:-
Shri Gurcharan Singh Saran, Presiding Judicial Member
Shri Vinod Kumar Gupta, Member
Shri Harcharan Singh Guram, Member
FIRST APPEAL NO. 62 OF 2011 2
ORDER
Gurcharan Singh Saran, Presiding Judicial Member The appellants/opposite parties No.1 to 4 (hereinafter referred as "OPs") have filed the present appeal against the order dated 10.12.2010 passed by the District Consumer Disputes Redressal Forum, SAS Nagar (Mohali) (hereinafter referred as "the District Forum") in consumer complaint No.326 dated 24.9.2010 vide which the complaint filed by the respondent/complainant(hereinafter referred as 'the complainant') was allowed with the direction to OP Nos. 1 to 4 to refund a sum of Rs. 2,85,538/-, medical expenses of Rs. 1 lac alongwith interest @ 9% per annum from the date of institution of the complaint till its payment and Rs. 10,000/- as litigation expenses.
2. The complaint was filed by the complainant that he was suffering from liver disease i.e. Cirrhosis with portal hypertension with decompensation since 4½ years approximately, accordingly, he visited PGIMER, Chandigarh for hospitalization but could not get the availability of the Bed. Then he visited OP No. 1 and on consultation with OP Nos. 2 to 4, it was revealed that the complainant needs hospitalization because of hepatic encephalopathy and it was also assured about the best medical treatment, accordingly, the complainant was admitted with Op No. 1 on 30.9.2009 and on the same day UGS Abdomen was got done by Dr. J.J. Singh. It was further revealed that the liver of the complainant was not enlarged. Parenchma shows no focal lesion. The billiary radicals and GB are FIRST APPEAL NO. 62 OF 2011 3 normal, further Pancreas and spleen appear normal. Pelvic study shows normal bladder. Mucosa slightly irregular. Prostate is not enlarged although wall of GB shows edema with enlarged spleenomegaly. It was also alleged that the complainant was discharged on 16.10.2009 in an unstable condition as the Doctor will not be available on that day as well as on 17.10.2009 due to Diwali Festival. This act of the Ops amounts to deficiency in service. The complainant was again admitted on 18.10.2009. Various other tests were conducted including UGI Endoscopy, which revealed that stomach Fundus full of blood, no gastric varix seen, multiple diffuse punctale haemorrhagic spots on the body and antral area, few of them actively oozing blood. A large clot seen over incisina/ pylorus, which may overlie. Ulcerated area, PHG bleed. Impression was given that there are Esophageal varices with severe PHG with bleed. Bleeding started in night of 18.10.2009 and continued till 21.10.2009. In the evening of 21.10.2009 the endoscopy was done and OP No. 2 & 3 had told that they could not detect as to from where the blood was coming and expressed their helplessness and advised to take the complainant to some other hospital specifically Fortis Hospital and accordingly, the complainant was shifted to Fortis Hospital on 22.10.2009. During the stay with Op No. 1, OP Nos. 2 to 4 gave various medicines and he was discharged by OP No. 1 Hospital in a serious and unstable condition with UGI Bleed on 22.10.2009 at about 10.30 a.m. and he reached Fortis Hospital at 11.24 a.m.. At the time, the condition of the complainant was totally drowsy. The Ops discharged the complainant when it was required immediate FIRST APPEAL NO. 62 OF 2011 4 intervention to stop the bleeding, which amounts to deficiency and unfair trade practice on the part of OP No. 1. OP No. 1 had raised a bill of Rs. 2,85,538/-. OP No. 1 was not having even basic facilities. In Fortis Hospital, he was attended by Dr. Mohnish Chabbra. Due care was given to the complainant by Doctors of OP No. 5 after conducting various tests and investigations, which included Hb, TLC, Platelets, Lymphocytes, segmented, neutrophils, creatinine, Urea etc.. UGI endoscopy was also done. Bowel Wash was started, USG Upper Abdomen, thereafter, very professional and proper treatment was given. One unit PRC Transfused. The complainant was started Ryle's Tube Lavage, Pantocid and somatostain infusion etc. and then Hepatic feed was started. As a result of that the condition of the complainant rapidly improved. The complainant was referred for Ophthalmology, Nephrology and Dermatology etc.. This type of treatment was missing with OP Nos. 1 to 4. The complainant had spent Rs. 2,63,842/- in hospitalization with OP No. 5. The hospitalization of OP Nos. 1 to 4 proclaimed to be a Super Speciality Hospital and accordingly, expectations are more, which was missing in their case, accordingly, it has been alleged that OP No. 1 to 4 have indulged in unfair trade practice and deficient in their services. Hence, the complaint with the direction to the Ops to pay a sum of Rs. 2,85,538/- incurred on the medicines, stay in hospital of OP Nos. 1 to 4, tests etc., a sum of Rs. 2,63,842/- on account of hospitalization with Op No. 5, Rs. 14 lacs on account of mental agony and harassment and Rs. 20,000/- as litigation expenses. FIRST APPEAL NO. 62 OF 2011 5
3. The case was contested by the Ops. OP Nos. 1 to 4, who filed written statement taking preliminary objections that the complainant has not approached the Hon'ble Forum with clean hands; he has mis-guided the Court by distorting the factual position by filing a false complaint in order to extort money; the complaint is liable to be dismissed as there is no negligence in the services on the part of OP Nos. 1 to 4. OP No. 2 Dr. Akhil Bhargava is MBBS, MD in Medicine and OP No. 3 Dr. Rahul Gupta is MBBS, MD Medicine with three years experience in Hepatology with PGIMER and OP No. 4 is MBBS, MD in the field of Psychiatry. On merits, it has been admitted that the complainant had come to their hospital in a semi oriented state and was diagnosed with Acute Alcoholic Hepatitis and Cirrhosis of the Liver. Other symptoms were Odema on feet and anorexia. He was suffering from liver disease i.e. Cirrhosis with Portal hyper tension in decompensated state for the last 4½ years. The condition of the complainant was induced by heavy alcohol intake over a prolonged period of time. He had been indulging in heavy alcohol for the last 15-20 years. He was hospitalised in the 2007 suffering from jaundice. Following such prognosis the complainant was in very clear term advised to refrain from indulging in regular intake of alcohol but despite that he had been taking the alcohol against the advice of the Doctors. The condition of the patient was thoroughly explained to the family members of the complainant and line of treatment to be followed was also clearly explained. Accordingly, he was admitted with Op No. 1 on 30.9.2009 and USG Abdomen with following observations was conducted:-
FIRST APPEAL NO. 62 OF 2011 6
"Liver not enlarged. Parenchyma shows no focal lesion. The billiary radicals and GB are normal. GB wall shows edema. Pancreas and spleen appear normal, both kidneys appear normal. Spleen enlarged.
Pelvic study shows normal bladder. No calculus or growth seen. Mucosa slightly irregular but bladder is not full. Prostrate is not enlarged. No node, abnormal fluid or mass seen."
4. It was observed that the complainant was having a history of consuming alcohol and Cirrhogenic doses i.e. in excess of 80 gm a day over a prolonged period of 15-20 years and he also showed features of decompensation in the form of Jaundice and Passage of Blood through stool. Due to continuing alcohol abuse, the complainant was suffering from Liver Disease - Cirrhosis and Portal Hypertension. The Gall Bladder Wall was shown edema, which means swelling of the tissues, which is not considered normal and is indicated injury to the liver. The treatment which is conducted with final destruction of blood cells and storage of blood and production of lymphocytes was found to be enlarged, the condition known as Spleenomegaly, which was chronic disease. Further he was discharged from hospital on 16.10.2009 in an unstable condition although he was responding favourably to the treatment. However, it was denied that the complainant/patient was discharged from OP No. 1 on 16.10.2009 in an unstable condition on account of Diwali on 17.10.2009. Since the patient was showing gradual improvement in his overall condition, rather it was the complainant/his attendants, who had requested for discharge in view of Diwali on 17.10.2009, although it was objected by the Doctors of OP and on the following day i.e. 18.10.2009, he again reported back to the hospital. On FIRST APPEAL NO. 62 OF 2011 7 20.10.2009, the condition of the complainant was stable. However, on 21.10.2009 as per the remarks of the OP Doctor on the progress sheet, the condition remained to be deteriorated as bleeding began to occur through the Ryle's Tube. Accordingly, UGI Endoscopy Report was conducted, according to which fundus was full of blood, the large clot seen over incisina/pylorus, which was not able to wash with saline. This report clearly defines that the complainant/patient had decompensated liver disease. Therefore, there must be some sort of acute injury over lying such area. Since the complainant was habitual drinker and when he was released on parole on Diwali Festival, he might have indulged in alcohol, which induced the condition whereby bleeding began to occur. During the period the complainant was hospitalized, his fluid and food was carefully checked according to which his health had improved. Only after the complainant got parole for night that his condition started deteriorating, however, the necessary treatment was administered to the complainant. It was denied that the condition of the complainant was unstable when he left the hospital on 16.10.2009. The complainant had left the hospital against the medical advice, discharge sheet and other relevant documents were given to him. The bill of the hospital was paid by the complainant. It was also denied that OP No. 1 did not have the basic facility for running the hospital or does not have the qualified or trained staff. It was also denied that OP Doctors were negligent and unethical. During the period, the complainant remained admitted with Op No. 1, complete universally medical accepted protocol was complied with with all necessary tests and medication. The FIRST APPEAL NO. 62 OF 2011 8 complainant was fully updated and informed about the treatment to be given. It was denied that the OP indulged in unfair and restrictive trade practices. No false representation was ever made regarding the quality and standard of the services to be provided. Op No. 1 well known reputed institution, enjoying a good name on account of standard of services and ultimately, it was stated that the complaint is without merit and the same be dismissed.
5. OP No. 5 was proforma respondent.
6. The parties were allowed by the learned District Forum to lead their evidence.
7. In support of his allegations, the complainant had tendered into evidence his affidavit Ex. CW-1/1, out patient ticket of PGI Ex. C-1, USG abdomen report Ex. C-2, discharge summary Ex. C-3, discharge summary Ex. C-4, consolidated bill of Silver Oak Hospital Ex. C-5, bills Exs. C-6 to C-66, discharge summary Ex. C- 67, prescription slip Ex. C-68, discharge handover form Ex. C-69, consolidated bill Ex. C70, bill of Fortis Hospital Ex. C71 to C91. On the other hand, opposite party Nos. 1 to 4 had tendered into evidence copies of Sleisenger and Fordtrans 9th edition Ex. R-1, report of USG Abdomen Ex. R-2, progress sheet Ex. R-3, progress sheet Ex. R-4, progress sheet Ex. R-5, UGI endoscopy report Ex. R-6, bill Ex. R-7.
8. After going through the allegations in the complaint, written statement filed by the OP, evidence and documents brought on the record, the learned District Forum vide impugned order observed that condition of the complainant was such that his hospitalization was required because firstly for that purpose he had FIRST APPEAL NO. 62 OF 2011 9 approached the PGI but on account of non-availability of the bed, he approached OP No. 1 and after consultation with the doctors he was advised hospitalization for a few days as he was suffering from alcohol related liver disease, which required regular monitoring by the complainant/patient. It was also observed that the treatment given by Op Nos. 1 to 4 was the treatment required for this patient and there was no proof with the complainant that Op Nos. 1 to 4 deviated from the standard line of treatment. It was also observed that the amount charged by the hospital cannot be said to be excessive. However, it was observed that when the complainant was discharged on 22.10.2009, he was in a serious condition. The Ops have failed to detect stop the blood oozing from him. The condition of the complainant had become critical saying that the treatment being given by the Ops was not responding to the complainant, therefore, they did not have any option but to get discharged from OP Nos. 1 to 4 and was taken to OP No. 5 where he was treated and the patient responded to the treatment given by them and ultimately, after full recovery, he was released from the hospital. The hospital of OP No. 1 had a good repudiation being Super Speciality Hospital, they were ready to admit the patient but they were unable to treat the patient when the patient was in a critical condition, which amounts to dereliction of duty and grave negligence on the part of OP Nos. 1 to 4 and on that ground the complaint was accepted as stated above.
9. Aggrieved with the order passed by the learned District Forum, the appellant/opposite parties have filed the present appeal.
10. We have heard the learned counsel for the parties. FIRST APPEAL NO. 62 OF 2011 10
11. In the grounds of appeal, it has been contended that the complainant had given false information with regard to the ailment from which he was suffering. According to the disease of the patient, appropriate treatment was given and the learned District Forum has not pointed out what ought to have been done and what has not been done by the Ops to give him the treatment and in case he left the hospital in LAMA and had taken the treatment from another hospital, which was almost on the same lines, it cannot be said that the treatment given by the Ops was not a proper treatment. There is no expert opinion that the treatment given by the appellants/Ops was not in line with the disease of the complainant. The doctor OP No. 2 is MBBS and MD in Medicine and OP No. 3 has three years experience in Hepatology from PGIMER whereas OP No. 4 has MD in Psychiatry, therefore, the Doctors, who treated the patient are qualified doctors, able to handle the patient, therefore, the observations of the learned District Forum that the Doctors of the Ops were not trained and experienced, although it was stated in the written statement that the Doctors are qualified and competent but there certificates were not attached. Now an application under Order 41 Rule 27 CPC has been preferred with a request to produce those certificates on the record showing that the Doctors are competent and qualified. Accordingly, it was submitted that the findings so recorded by the learned District Forum are liable to be set-aside.
12. Firstly taking application under Order 41 Rule 27 CPC, the proceedings under the Act are summary in nature. The Ops in their written statement have mentioned the qualification and FIRST APPEAL NO. 62 OF 2011 11 experience of doctor but their certificates were not produced on the record of which the learned District Forum took a note that certificates have not been produced about the qualifications of the Doctors. Since strict principles of C.P.C. and Evidence Act are not applicable, therefore, we allow the application to produce qualification, certificate of the doctors of the Op on the record. In case we see these certificates all the three doctors are M.D. in their field. Therefore, they are trained doctors having requisite qualification and experience.
13. In case we go through the findings recorded by the learned District Forum, it has been observed that condition of the complainant was such that it required hospitalization as the complainant was suffering from Cirrhosis of liver and was a case of acute alcoholic hepatitis with history of regular intake of the alcohol for the last 15-20 years and was also admitted in the year 2007 with the problem of Jaundice. It was also observed that bleeding in the upper USG of the complainant occurred on 20.10.2009 due to insertion of RT in his abdomen. It was further observed that the complainant has not been able to demonstrate and prove any dereliction on the part of OP Nos. 1 to 4 on the standard line of treatment. The charges charged by OP No. 1 were not excessive rather less what has been charged by OP No. 5. However, on 20- 21.10.2009, the condition of the complainant became critical as Ops were unable to stop the bleeding and ultimately, the patient was taken to Fortis Hospital OP No. 5 where he was got treated. It has been observed by the learned District Forum that Op Nos. 1 to 4 could not manage the patient when he was in critical condition. FIRST APPEAL NO. 62 OF 2011 12 Therefore, they are deficient in services and are adopting unfair means when they admit the patient with the assurance that this is a Super Speciality Hospital with all type of critical management but when the patient is in critical condition, they referred to an other hospital.
14. Now we have to check in whether the condition so observed by the learned District Forum is correct or not? It has been contended by the counsel for the appellants that the observations so made by the learned District Forum are without any basis. The patient was admitted in the hospital on 30.9.2009 and upto 16.10.2009, he remained admitted in this hospital and the treatment chart filed on the record as Ex. R-3 shows that on upto that day his condition was stable. In the complaint, it has been pleaded by the complainant that on 16.10.2009, it was pleaded by the Ops to get relieve as they will not be available due to Diwali Festival but it is incorrect because the leave was taken by the attendants of the patient despite resistance from the Ops because for the management of the patient like this, they need regular management for atleast 20 days. Ex. R-4 is the writing given by Satwant Kaur wife of the complainant, it reads as under:-
"Going home today at 12.00 PM. Will come back in the morning at 9.00 A.M. Sd/- Satwant Kaur 17.10.2009"
and on the next day, they reported in the hospital. During that period, the complainant did not make any complaint with regard to the management and treatment of the patient, therefore, the allegations that the Doctors themselves discharged the patient from the hospital FIRST APPEAL NO. 62 OF 2011 13 are incorrect, rather, the discharge of the patient was resisted by the Ops but on their consistent request on account of Diwali Festival, he be given for one night parole. When he came back he remained stable for 18-19th but on 20th, there was active GI bleed. In view of the findings given by the learned District Forum that injury in the UGI was not on account of insertion of Ryle's Tube (RT) and these findings have not been challenged by the complainant by way of filing any cross appeal. The endoscopy of UGI was done on 21.10.2009, which is Ex. C-3 which reads as under:-
"Esophagus Upper 2/3rd : Gr 1 x 2 col of esophageal varices Lower 1/3rd : No RCS/CRS/ red white sign, no bleed seen. GE Junction Other:
Stomach : Fundus - full of blood, however no gastric varix seen, Multiple diffuse punctale haemorrhagic spots seen on body & antral area, few of them actively oozing blood A large clot seen over incisina/pylorus which may overlie? Ulcerated area" PHG bleed Not able to wash with saline, so scope not passed beyond antrum/pylons.
Duodenum
DL D2 : not seen
Impression : Esophageal varicus
Severe PHG with bleed
?? ulcer at incisina with overlying clot, no fresh blood overthal area " PHG bleed.
Plan : CST
Add Sucramol Syp (10ml QID)"
15. In case the injury was not due to RT then it is an admitted case that the complainant was patient of Cirrhosis of liver and keeping in view the condition of the stomach as referred above, "oozing of blood due to condition of the liver" for which the treatment FIRST APPEAL NO. 62 OF 2011 14 has been given by OP Nos. 1 to 4 to control that first step (Ceph) was to give conservative treatment but in case HB falls down then to transfuse the blood. Surgery was the last resort in case it is not controlled in any manner. The treatment chart will reveal that on 20.10.2009 his condition was stable in the morning with BP 120/80mmHg pulse rate normal. However, in the evening, there was bleeding from the GI and conservative treatment in the form of injections and tablets was given. On 21.10.2009, the observations were that the patient is alcoholic cirrhosis, decompensated ascetics, Jaundice, coagulopathy, active upper GI bleed, pulse rate was 120/60 and heart rate 110 per minute and there was fresh active blood transfusion. Since the HB was 5.1, therefore, it was recommended transfuse for 4 O FFP. Then there is advise of transfuse whole blood fast and on 22.10.2009, the patient was shifted to OP No. 5. Therefore, immediately what was required was to give medicines and transfuse the blood, which has been done by the Ops.
There is no expert report that the treatment given by OP Nos. 1 to 4 is not according to medical sciences. Even the learned District Forum in its judgment in Para No. 14 has observed that the complainant has not been able to demonstrate any deviation on the part of OP Nos. 1 to 4 from the standard line of treatment. In case the standard line of treatment has been given by Ops No. 1 to 4 then how they can be deficient in their services. In case of injuries to the liver on account of cirrhosis of liver, it may take time for couple of days to stop the bleeding because immediately surgery is not recommended and efforts should be made to treat it conservatively to maintain the health FIRST APPEAL NO. 62 OF 2011 15 of the patient. Blood transfusion is recommended to make good loss of the blood, which has been done by OP Nos. 1 to 4. In case due to some apprehensions in the mind of the attendants of the patient, they have taken the patient to some other hospital and lateron the patient recovered, it cannot be said that the treatment given by OP Nos. 1 to 4 was defective one.
16. In what cases, the Doctor can be held liable for medical negligence, the standards have been fixed by the Hon'ble Supreme Court in the judgment of "Kusum Sharma and others versus Batra Hospital & Medical Research Centre & Others", 2010(3) SCC 480 and issued the guidelines that the following principles must be kept in mind while deciding whether the medical professional is guilty of medical negligence:-
"I. Negligence is the breach of a duty exercised by omission to do something which a reasonable man, guided by those considerations which ordinarily regulate the conduct of human affairs, would do, or doing something which a prudent and reasonable man would not do. II. Negligence is an essential ingredient of the offence. The negligence to be established by the prosecution must be culpable or gross and not the negligence merely based upon an error of judgment. III. The medical professional is expected to bring a reasonable degree of skill and knowledge and must exercise a reasonable degree of care. Neither the very highest nor a very low degree of care and competence judged in the light of the particular circumstances of each case is what the law requires.
IV. A medical practitioner would be liable only where his conduct fell below that of the standards of a reasonably competent practitioner in his field.
V. In the realm of diagnosis and treatment there is scope for genuine difference of opinion and one professional doctor is clearly not negligent merely because his conclusion differs from that of other professional doctor.FIRST APPEAL NO. 62 OF 2011 16
VI. The medical professional is often called upon to adopt a procedure which involves higher element of risk, but which he honestly believes as providing greater chances of success for the patient rather than a procedure involving lesser risk but higher chances of failure. Just because a professional looking to the gravity of illness has taken higher element of risk to redeem the patient out of his/her suffering which did not yield the desired result may not amount to negligence.
VII. Negligence cannot be attributed to a doctor so long as he performs his duties with reasonable skill and competence. Merely because the doctor chooses one course of action in preference to the other one available, he would not be liable if the course of action chosen by him was acceptable to the medical profession.
VIII. It would not be conducive to the efficiency of the medical profession if no Doctor could administer medicine without a halter round his neck. IX. It is our bounden duty and obligation of the civil society to ensure that the medical professionals are not unnecessary harassed or humiliated so that they can perform their professional duties without fear and apprehension.
X. The medical practitioners at times also have to be saved from such a class of complainants who use criminal process as a tool for pressurizing the medical professionals/hospitals particularly private hospitals or clinics for extracting uncalled for compensation. Such malicious proceedings deserve to be discarded against the medical practitioners.
XI. The medical professionals are entitled to get protection so long as they perform their duties with reasonable skill and competence and in the interest of the patients. The interest and welfare of the patients have to be paramount for the medical professionals."
17. Counsel for the complainant/respondent has not been able to pin-point how the Doctors were negligent in the treatment and are covered under the guidelines given by the Hon'ble Supreme Court. In case attendants have shifted the patient to some other hospital due to some apprehension in their mind that does not mean that the hospital was not ready to treat the patient in a critical condition. It is the faith of the patient or their attendants to get the treatment from this hospital or some other hospital. In case the FIRST APPEAL NO. 62 OF 2011 17 patient opts for an other hospital, one cannot give the findings that this hospital was unable to treat the patient.
18. Therefore, unless and until negligence is proved, unnecessarily Doctors cannot be burdened so that they loose faith in the system and does not come forward to the rescue of the patients, therefore, we are of the opinion that the findings so recorded by the learned District Forum regarding the negligence of the Ops are not correct and we set aside the same.
19. Sequel to the above discussion, we find merit in the appeal filed by the appellants and the same is accepted. The complaint of the complainant is dismissed being without any merit. No order as to costs.
20. The arguments in this appeal were heard on 3.3.2014 and the order was reserved. Now the order be communicated to the parties as per rules.
21. The appellants had deposited an amount of Rs. 25,000/- with this Commission at the time of filing the appeal. This amount of Rs. 25,000/- with interest accrued thereon, if any, be remitted by the registry to appellant No. 1 by way of a crossed cheque/demand draft after the expiry of 45 days.
22. The appeal could not be decided within the statutory period due to heavy pendency of Court cases.
(Gurcharan Singh Saran) Presiding Judicial Member (Vinod Kumar Gupta) Member March 7, 2014. (Harcharan Singh Guram) as Member FIRST APPEAL NO. 62 OF 2011 18