Date of filing: 29.06.2012.

Date of disposal: 22.11.2012.

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM - II:

VIJAYAWADA, KRISHNA DISTRICT

Present: Sri A. M. L. Narasimha Rao, B.Sc., B. L., President

Smt N. Tripura Sundari, B. Com., B. L., Member

Sri S. Sreeram, B.Com., B.A., B.L., Member

Thursday, the 22nd day of November, 2012

C.C.No.118 of 2012

Between:

Smt Padmavathi, W/o Venkata Subrahmanyam, Housewife and Properties, R/o Jupudi Village, Ibrahimpatnam Mandal, Krishna District.

. … Complainant.

And

Dr.U.V. Ramana, M.B.B.S., DCH., M.S. Ortho, Trust Hospital, D.No.40-9-58A, Sub- Registrar Office Road, Kalanagar, Benz Circle, Vijayawada – 520 010.

. … Opposite Party.

This complaint coming on before the Forum for final hearing on 070.11.2012, in the presence of Sri K.M.S. Sastry, advocate for complainant; Sri B. Samba Siva Rao, advocate for opposite party and upon perusing the material available on record, this Forum delivers the following:

O R D E R

(Delivered by Hon’ble President Sri A. M. L. Narasimha Rao)

1. This complaint is filed under Section 12 of Consumer Protection Act, 1986 seeking direction to the opposite party to pay compensation of Rs.13,20,000/- with interest thereon and to pay costs.

2. Initially the complaint is filed against the opposite party and two others but the case was admitted and registered only against the opposite party. The averments of the complaint in brief are as follows: The complainant had developed pain at finger joints and took first aid from a local medical practitioner in the last week of December, 2010. As there was no response and on his advice the complainant approached the opposite party in the

2nd week of January, 2011. At that time she had pain only at finger joints. The opposite party assured best and expert treatment and told that she would cure up ailment. He prescribed tests and medicines. The complainant was treated as inpatient and also as out patient from January, 2011 to May, 2011. The opposite party told initially that the complainant had routine mscular pain and assured from time to time that she would get relief. The complainant visited the opposite party on 19.1.2011 and 24.1.2011 initially. There after on 18.4.2011 the pain extended from elbow level to neck when she approached the opposite party he advised x-ray and 2 changed the medicines. Again on 27.4.2011 when the pain extended up to legs xray was taken again and he was told that the pains are normal and routine. The opposite party changed the medicine. On 7.5.2011 the complainant approached the opposite party as there was no improvement and MRI scan was advised. After seeing the MRI scanning report the complainant was told on 9.5.2011 that there was no defect in the scanning report and he was advised physiotherapy. The complainant visited the opposite party on 14.5.2011 and on 21.5.2011. She had undergone physiotherapy from 22.5.2011 to 26.5.2011 by then the complainant started to have back pain. There after the complainant approached Dr. Boppana Chetan (originally joined as 2nd opposite party) on 18.7.2011 and he told that as consequence of treatment by the opposite party the complainant had developed rheumatic pains and it is in aggravated form and the prospects of recovery are not bright and that relief may not be more than 20%. The said Dr. Chetan advised blood test and thyroid test and prescribed medicines for one month initially and later changed the medicines and prescribed for extension of treatment. The complainant was feeling stability in the pain but the pains have not receded. When spray medicines were advised they were giving relief for two or three hours. Dr. Chetan told that injection valuing up to Rs.40,000/- approximately have to be taken once in every six months. In that connection Dr. Ramana Reddy was consulted he told that even using such injections may or may not be useful. There after the complainant approached NIMS hospital on 15.10.2011. Doctors at NIMS hospital told the complainant that treatment given to her by the opposite party is not on proper lines and that the disease had aggravated to 80% stage. She was advised to undergo blood tests and taken medicines and injections. She was treated for one month.

The complainant is continuing her treatment as advised by NIMS. There are no prospects of recovery. The complainant has to experience pain, discomfort and other complications for rest of her life. She was told that the problem may extend to the heart and the complainant has to be prepared for any kind of eventuality. Further enquiries of the complainant revealed that the disease is in aggravated from on account of wrong diagnosis and treatment on wrong lines and in Ayurveda the expenses for treatment would be Rs.1,00,000/- with no assured recovery. The complainant incurred an amount of Rs.75,000/- for the treatment by the opposite party, a sum of Rs.60,000/- for the treatment from Dr. Chetan and Rs.25,000/- for the treatment given by NIMS. The complainant was deprived of her routine life for a period of one year. The complainant therefore claims compensation and accordingly issued notices to the opposite party, to Dr. Chetan and to NIMS. The opposite party sent a reply with false averments. NIMS had sent reply asking for further particulars and on complainant furnishing further particulars and issuing another notice NIMS did not give reply. Dr. Chetan also did not give any reply. Therefore the present complaint is filed for compensation, interest and costs.

4. The opposite party filed his version denying the allegation made in the complaint and further stating as follows: The complainant approached the opposite party on 19.1.2011. She was never admitted in the hospital. The opposite party treated her as outpatient. The complainant complained pain and swelling of right hand and shoulder for three days. She reported no fever. The opposite party had given symptomatic treatment as per standard Medical Protocol. The opposite party did not say that the pain is routine mmuscular pain and that treatment for three days would bring the patient to normal condition. The complainant again came on 24.1.2011 but she did not say that pain had extended up to elbow level within 5 days of treatment. No additional medical treatment was prescribed. The complainant reported relief of pain and so medicines were reduced and only two types of tablets were prescribed for a period of 10 days. The complainant did not turn up for follow up/review for three months there after. The complainant came to the opposite party on 18.4.2011 complaining pain and swelling of both hands and knees. She was told that she had Polyarthralgia which needs prolonged treatment. Injections were given and medicines were prescribed. The complainant again came on 25.4.2011 and reported relief of pain and so same tablets continued. Again on 7.5.2011 tablets were prescribed. On 9.5.2011 the  complainant complained of neck pain radiating to both of her hands. The 1st opposite party advised MRI scan of cervical spine. That scan report revealed ‘Grossly Normal MRI study of cervical Spine’. She was advised physiotherapy and cervical traction in addition to medicines. On 14.5.2011 crepe bandage was given and tablets were prescribed. On 21.5.2011 the complainant came back to the 1st opposite party with complaints of poly arthritis. Then the 1st opposite party told her that she must be having Rheumatoid Arthritis (RA) as she had persistent joint pains for more than 6 weeks. The opposite party started to prescribe DMARD durgs on 21.5.2011. The same drugs were prescribed by Dr. Chetan and Dr. Suresh at NIMS. On 25.5.2011 an injection was given for pain relief and the complainant was advised to consult rheumatologist. There after the complainant did not come to the opposite party. Rheumatoid Arthritis is a chronic inflammatory disease. It requires prolonged treatment and it is a progressive disease. Diagnosis of Rheumatoid Arthritis is based on clinical findings if the joint pains persist for more than 6 weeks. The opposite party never deviated from standard protocol diagnosis and treatment. For the notices issued by the complainant the opposite party had sent reply asking for copies of x-ray, medical bills etc., for giving detailed reply. The complainant did not send the documents. The complainant paid only Rs.400/- towards doctors fee to the opposite party. She must have spent less than Rs.7,000/- towards medicines, tests, MRI scan etc., for the treatment given by the opposite party. There is no deficiency in service on the part of the opposite party. The complaint is liable to be dismissed.

5. The complainant filed her affidavit and additional affidavit which are received as evidence of PW-1. The opposite party filed his affidavit and it is received evidence of DW-1.

6. Exs.A1 to A18 are marked for the complainant and no documents are marked for the opposite parties.

7. Heard the arguments advanced by both the parties. The complainant also filed written arguments. The medical literature filed by both the parties is also considered.

8. The points that fall for determination are:

I) Whether there is negligence on the part of the opposite party in treating the complainant for Rheumatoid Arthritis and in advising her?

II) Whether the complainant is entitled to the reliefs prayed for?

Point No.1:

9. The grievance of the complainant is that the opposite party had not given proper treatment and that has given rise to the complainant developing Rheumatoid Arthritis. This appears to be the ground from averments made in the complaint particularly statements that Dr. Chetan told the complainant that as consequence of treatment by the opposite party she developed rheumatic pains and it was at the aggravated form by the time of examination by Dr. Chetan. The complainant also stated that the doctors at NIMS told that the treatment given by the opposite party was not on proper lines. So first it is necessary to see if there is negligence on the part of the opposite party in giving proper treatment.

10. The complainant admittedly first visited the opposite party on 19.1.2011. On that day blood and urine tests was advised and medicines were prescribed as per the copy of case sheet Ex.A1. The blood report shows high value of ESR and slightly low count of hemoglobin. As per the case sheet the complainant again visited the opposite party on 24.1.2011 and there after on 18.4.2011. The case sheet shows that the complainant has complained pain extending to elbow on 24.1.2011. According to opposite party he told the complainant on 18.4.2011 that she has Polyarthralgia and it needs prolonged treatment. It may mean inflammation of several joints. So by 18.4.2011 the complainant had pain and swelling in several joints. The complainant again came to hospital on 27.4.2011. According to the opposite party on that day the complainant reported relief of pain and therefore same tablets were continued. The case sheet does not show any further complaint noted on 27.4.2011. But the doctor had noted ESR 60 mm on that day while the blood report was obtained on 19.1.2011 itself. It is not known why the opposite party had made reference to the abnormal ESR on that day. The complainant later visited on 7.5.2011 and 9.5.2011 on which day she complained of neck pain radiating to her both hands. The opposite party advised MRI scan of cervical spine. MRI scan revealed grossly normal cervical spine. The complainant had advised

physiotherapy and cervical traction. This is also noted on the case sheet. On 14.5.2011 the complainant was prescribed medicines and crepe bandage was applied. On 21.5.2011 the complainant again went to the opposite party and on that day the opposite party told her that she must be having Rheumatoid Arthritis. So from, 19.1.2011 to 21.5.2011 the opposite party could not diagnose the disease as RA and consequently the treatment for RA had delayed. This is highlighted by the complainant to attribute negligence to the opposite party.

11. The learned counsel for the complainant produced some literature and on the basis of literature he submits that the opposite party should have advised blood test to notice rheumatoid factor and as it was not done the treatment for Rheumatoid Arthritis was delayed. The learned counsel for the opposite party contends that joint pains may occur for several reasons and Rheumatoid Arthritis is one of them and treatment for Rheumatoid Arthritis cannot be started initially unless the patient is under observation at least for six weeks with continuous treatment to reduce pain. In the present case the complainant initially attended on 19.1.2011 and 24.1.2011 and there after she did not turn up for about 3 months and even on 18.4.2011 the opposite party found that the complainant had Polyarthralgia and commenced treatment and after treatment for about a month and when there was pain at several places, the opposite party had diagnosed that the complainant had Rheumatoid Arthritis and accordingly commenced treatment on 21.5.2011. It is not known if the complainant had taken medicines continuously till 18.4.2011 we may not assume that she was on continuous medication right from 19.1.2011. The complainant has not produced any material to show that she took treatment any where or if she continued to take medicines prescribed by the opposite party on 19.1.2011 and 24.1.2011. Therefore 18.4.2011 must be taken as the fresh starting day for treatment again. If 6 weeks treatment is required to confirm Rheumatoid Arthritis the opposite party had diagnosed within that period i.e., on 21.5.2011. Then it cannot the said that there is negligence on the part of the opposite party.

12. We may refer to the medical literature produced by both the counsel relating to Rheumatoid Arthritis. The learned counsel for the opposite party refers to text of Davidson’s Principles & Practice of Medicine. At page.1088 of said text book (21st edition) the following extract is relied upon: “Functional capacity decreases most rapidly at the beginning of disease and the functional status of patients within their first year of Rheumatoid Arthritis is often predictive of long-term outcome. Factors that associate with a poorer prognosis are disability at presentation, female gender, involvement of MTP joints, smoking and a positive Rheumatoid Factor and anti-CCP. It is hoped that the prognosis of Rheumatoid Arthritis will improve as more aggressive early treatment is used but this has yet to be demonstrated”. 13. The learned counsel for the complainant relies upon an article from www.patient.co.uk with title Rheumatoid Arthritis and he also relied upon an article from www.webmd.com with title “Blood Tests to Diagnose Arthritis”. According to article Rheumatoid Arthritis it is difficult at first for a doctor to say that the patient had definitely Rheumatoid Arthritis because there are many other causes of joint pains and as there is no single test which diagnoses early Rheumatoid Arthritis with 100%

certainty. It is further noted a doctor may diagnose Rheumatoid Arthritis basing on typical symptoms, blood test and x-ray of hands or feet and the patient may also be advised to have a range of blood test to rule out cause of joint pains. The relevant text on symptoms and progress from that article reads as follows:

What are the symptoms of rheumatoid arthritis?

Joint symptoms

The common main symptoms are pain and stiffness of affected joints. The stiffness is usually worse first thing in the morning, or after you have been resting. The inflammation causes swelling around the affected joints.

Other symptoms

These are known as extra-articular symptoms of Rheumatoid Arthritis (meaning outside of the joints). A variety of symptoms may occur. The cause of some of these is not fully understood: Small painless lumps (nodules) develop in about 1 in 4 cases. These commonly occur on the skinover the elbows and forearms, but usually do no harm.

Inflammation around tendons may occur. This is because the tissue which covers tendons is similar to the synovium around the joints. Anaemia and tiredness are common. A fever, feeling unwell, weight loss, and muscle aches and pains sometimes occur. In a few cases, inflammation develops in other parts of the body, such as the lungs, heart, bloodvessels, or eyes. This is uncommon but, if it occurs, can cause various symptoms and problems which are sometimes serious.

How does rheumatoid arthritis develop and progress?

In most cases the symptoms develop gradually - over several weeks or so. Typically, you may first develop some stiffness in the hands, wrists, or soles of the feet in the morning, which eases by mid-day. This maycome and go for a while, but then becomes a regular occurence. You may then notice some pain and swelling in the same joints. More joints such as the knees may then become affected. In a small number of cases, less common patterns are seen. For example:

In some cases pain and swelling develop quickly in many joints - over afew days. Some people have bouts of symptoms which affect several joints. Each bout lasts a few days, and then goes away. Several bouts may occur before persistent symptoms develop. In some people, usually young women, the disease affects just one or two joints at first, often the knees. The non-joint symptoms such as muscle pains, anaemia, weight loss, and fever are sometimes more obvious at first before joint symptoms develop. The severity of Rheumatoid Arthritis can vary greatly from person to person. It is usually a chronic relapsing condition. Chronic means that it is persistent. Relapsing means that at times the disease flares up  elapses), and at other times it settles down. There is usually no apparent reason why the inflammation may flare up for a while, and then settle down. If untreated, most people with Rheumatoid Arthritis have this pattern of flare-ups followed by better spells. In some people, months or even years may go by between flare-ups. Some damage may be done to affected joints during each flare-up. The amount of disability which develops usually depends on how much damage is done over time to the affected joints. In a minority of cases the disease is constantly progressive, and severe joint damage and disability can develop quite quickly. 14. In the article taken from ‘webmd’ by the complainant there are other parts of the article not produced by the complainant. They refer to diagnosis. The relevant part reads as follows:

Diagnosing rheumatoid arthritis (RA) in the early stages can be difficult. There is no single test that can clearly identify rheumatoid arthritis. Instead, doctors diagnose rheumatoid arthritis based on factors that are strongly associated with the disease. The American College of Rheumatology uses this list of criteria:

1. Morning stiffness in and around the joints for at least one hour.

2. Swelling or fluid around three or more joints simultaneously.

3. At least one swollen area in the wrist, hand, or finger joints.

4. Arthritis involving the same joint on both sides of the body (symmetric arthritis).

5. Rheumatoid nodules, which are firm lumps in the skin of people with rheumatoid arthritis. These nodules are usually in pressure points of the

body, most commonly the elbows.

6. Abnormal amounts of rheumatoid factor in the blood.

7. X-ray changes in the hands and wrists typical of rheumatoid arthritis, with destruction of bone around the involved joints. However, these changes are typical of later-stage disease.

Rheumatoid arthritis is officially diagnosed if four or more of these seven factors are present. The first four factors must have been present for at least six weeks.

More recently, guidelines have changed somewhat in an attempt to diagnose RA in its earlier stages. Symptoms of rheumatoid arthritis can come and go but are usually persistent. To diagnose RA, your doctor may need to see your joints when the disease is active for several reasons:

 Patients may find it hard to describe symptoms to doctors in a way that allows them to make the diagnosis.

 Rheumatoid arthritis can appear similar to other common causes of joint pain, leading to the wrong diagnosis.

 Patients often think they are feeling "normal" aches and pains and ignore or just live with their symptoms for a long time before seeking treatment. Several diseases can masquerade as rheumatoid arthritis, which contributes to the difficulty in diagnosis. These other diseases include:

Osteoarthritis

 Gout

 Fibromyalgia

Other autoimmune diseases such as systemic lupus erythematosus (lupus)  Joint inflammation caused by infections

Because of these difficulties, a proper diagnosis is often missed early on. In fact, the average time between the onset of symptoms and the official diagnosis of rheumatoid arthritis is almost nine months.

Though diagnosing rheumatoid arthritis isn't easy, it is extremely important to correctly identify those with the disease. Delaying the diagnosis can be harmful because joint damage can occur early in the disease. Some experts think that blocking early joint damage can have huge long-term benefits.

The problem arises when it looks like someone has rheumatoid arthritis but they don't yet meet the criteria for diagnosis. If someone doesn't actually have it, it would be wrong to treat them because the drugs used to treat Rheumatoid Arthritis are powerful and can have serious side effects.

15. The learned counsel for the opposite party cites the following lines said to be from text book, Mercer’s Orthopedic Surgery, Volume.2, Page.757:

Diagnosis

The American Rheumatism Association have revised their diagnostic criteria (Arnett, 1989);

1. Morning stiffness, lasting atleast one hour.

2. Arthritis of three or more joint areas with soft tissue swelling or fluid – observed by a physician – in upper and lower limbs.

3. Arthritis of hand joints (including wrist and/or metacarpals).

4. Symmetrical Arthritis – simultaneous involvement of same joint areas on both sides of the body.

5. A positive serum Rheumatoid Factor.

6. Radiological changes – especially of hands and wrist, ankle and foot, showing subchondral erosions, bony decalcification, symmetrical articular cartilage loss.

7. Subcutaneous nodules. Criteria 1 – 4 should be present for at least 6 weeks to make a diagnosis of Rheumatoid Arthritis.

16. We find from the website of National Institute of Health some relevant information given below;The revised criteria for the classification of rheumatoid arthritis (RA) were formulated from a computerized analysis of 262 contemporary, consecutively studied patients with RA and 262 control subjects with rheumatic diseases other than Rheumatoid Arthritis (non-RA). The new criteria are as follows: 1) morning stiffness in and around joints lasting at least 1 hour before maximal improvement; 2) soft tissue swelling (arthritis) of 3 or more joint areas observed by a physician; 3) swelling (arthritis) of theproximal interphalangeal, metacarpophalangeal, or wrist joints; 4) symmetric swelling (arthritis); 5) rheumatoid nodules; 6) the presence of rheumatoid factor; and 7) radiographic erosions and/or periarticular osteopenia in handand/or wrist joints. Criteria 1 through 4 must have been present for at least 6 weeks. Rheumatoid arthritis is defined by the presence of 4 or more criteria, and no further qualifications (classic, definite, or probable) or list of exclusions are required. In addition, a "classification tree" schema is presented which performs equally as well as the traditional (4 of 7) format. The new criteria demonstrated 91-94% sensitivity and 89% specificity for Rheumatoid Arthritis when compared with non-RA rheumatic disease control subjects.

17. The learned counsel for the complainant states that a blood test for Rheumatoid factor would have disclosed the presence of the disease at an early stage and early treatment could have given better results. From the literature we extracted, it cannot be readily said that Rheumatoid factor test is sufficient to diagnose RA. As observed above, the opposite party had given continuous treatment from 18.4.2011 to 25.5.2011. It is less than 6 weeks. Blind treatment for Rheumatoid Arthritis is not advisable. The material placed by the complainant including the medical certificate Ex.A18 issued by NIMS does not show that the opposite party was negligent or that his treatment was improper or that due to improper treatment the complainant had developed Rheumatoid Arthritis. We therefore find that there is no negligence committed by the opposite party and there is no deficiency on his part in giving treatment to the complainant.

18. The learned counsel for the complainant further submits that the opposite party ought to have informed the complainant about the prognosis of the disease and remote chances of complete cure and should have advised to seek alternative system of treatment as there is no complete cure in Allopathic system of treatment.

As observed above the prognosis is not certain and not easily predictable. That apart the complainant did not take treatment for long time from the opposite partyafter she was diagnosed to have Rheumatoid Arthritis. The opposite party not being a person adept in other or alternative systems of medicine is not supposed to give advice to the complainant to seek some other system of treatment. In this regard also we do not find any deficiency on the part of the opposite party.

Point No.2:

19. In the view of the answer on point no.1 that there is no deficiency in service on the part of the opposite party, the complainant cannot claim any amount from the opposite party. We are not inclined to burden the complainant with costs. 20. In the result this complaint is dismissed without costs.

Typewritten by Steno N. Hazarathaiah, corrected by me and pronounced by us in the open Forum, this the 22nd day of November, 2012.

PRESIDENT                                                                                                MEMBER                                                            MEMBER

Appendix of evidence

Witnesses examined

For the complainant:                                                                                    For the opposite party:

PW – 1, Smt Padmavathi,                                                                              DW-1 Dr. U.V. Ramana,

(by affidavit)                                                                                                     (by affidavit).

Documents marked

On behalf of the complainant:

Ex.A1 Photocopies of bunch of medical prescriptions and bills etc.

Ex.A2 18.07.2011 Photocopies of bunch of medical prescriptions and bills etc.

Ex.A3 Photocopies of bunch of medical prescriptions and bills etc.

Ex.A4 26.11.2011 Photocopy of legal notice got issued by complainant to OP.

Ex.A5 10.12.2011 Copy of reply notice got issued by OP the complainant.

Ex.A6 Postal acknowledgement.

Ex.A7 18.12.2011 Original copy of letter issued by NIMS to complainant’s counsel.

Ex.A8 17.12.2011 Carbon copy of letter issued by complainant’s counsel to Superintendent, NIMS.

Ex.A9 Postal acknowledgement.

Ex.A10 05.01.2012 Original copy of letter issued by NIMS to complainant’s counsel.

Ex.A11 16.01.2012 Carbon copy of letter issued by complainant’s counsel to Superintendent, NIMS.

Ex.A12 22.05.2012 Copy of legal notice got issued by complainant’s counsel to NIMS.

Ex.A13 Postal acknowledgements.

Ex.A14 04.06.2012 Original copy of letter issued by NIMS to complainant’s counsel.

Ex.A15 08.06.2012 Copy of letter issued by complainant’s counsel to Superintendent, NIMS.

Ex.A16 16.08.2011 Copy of letter got issued by complainant to OP.

Ex.A17 Postal acknowledgement.

Ex.A18 05.10.2012 Photocopy of medical certificate issued by NIMS.

On behalf of the opposite parties: -Nil-

PRESIDENT