Lowrey v. Fairfield Med. Ctr. (Full Text)

Lowrey v. Fairfield Med. Ctr. (Full Text)

[Cite as Lowrey v. Fairfield Med. Ctr., 2009-Ohio-4470.]

COURT OF APPEALS
FAIRFIELD COUNTY, OHIO
FIFTH APPELLATE DISTRICT

Plaintiff-Appellant

CHARLES LOWREY, M.D.

-vs-

FAIRFIELD MEDICAL CENTER, et al.

Defendants-Appellees

JUDGES:
Hon. W illiam B. Hoffman, P. J.
Hon. John W . W ise, J.
Hon. Julie A. Edwards, J.

Case No. 08 CA 85

O P I N I O N

Civil Appeal from the Court of Common
Pleas, Case No. 04 CV 1196

Affirmed

August 28, 2009

For Defendant-Appellee Fairfield

RICHARD S. LOVERING
ERIC S. BRAVO
BRICKER & ECKLER
100 South Third Street
Columbus, Ohio 43215

CHARACTER OF PROCEEDING:

JUDGMENT:

DATE OF JUDGMENT ENTRY:

APPEARANCES:

For Plaintiff-Appellant

D. JOSEPH GRIFFITH
NICHOLAS R. GRILLI
DAGGER, JOHNSTON, MILLER
OGILVIE & HAMPSON
144 East Main Street, P. O. Box 667
Lancaster, Ohio 43130-0667

Fairfield County, Case No. 08 CA 85

2

Wise, J.

{¶1} Appellant Charles Lowrey, M.D. appeals the decision of the Fairfield

County Court of Common Pleas granting summary judgment in favor of Fairfield

Medical Center.

STATEMENT OF THE FACTS AND CASE

{¶2} After a series of incidents involving Dr. Lowrey’s conduct at Fairfield

Medical Center (“the Hospital”), the Hospital Board of Directors recommended that Dr.

Lowrey’s medical staff privileges be suspended. The parties subsequently entered into a

January 8, 2003, Settlement Agreement which provided, inter alia, that Dr. Lowrey

could reapply for staff privileges and that his application “will be evaluated on the same

basis as any other physician applying for Medical Staff Appointment and Clinical

Privileges.”

{¶3} On December 17, 2004, Dr. Lowrey filed the initial Complaint in this case

alleging, among other cla ims, various breaches of the Sett lement Agreement by the

Hosp ita l. Through amend ing h is Comp la int, Dr. Lowrey eventually a lleged e leven

counts aga inst the Hosp ital and former defendants. A ll but two of these Counts were

e lim inated via vo luntary d ism issa l, summary judgment, or both. Th is left on ly Counts

One and S ix. In Count One, Dr. Lowrey a lleged that the Hosp ita l breached

Paragraphs 4(a) and 4(b)(1)(2) of the Settlement Agreement by “fa iling to supp ly

[h is] patients with appropriate contact information and by fa iling to inform [h im] of

pat ient requests.” In Count S ix, he a lleged that the Hosp ita l breached Paragraph

Two of the Settlement Agreement by fa iling to cons ider h is applicat ion for med ical

Fairfield County, Case No. 08 CA 85

3

staff appo intment and clin ica l privileges at the Hosp ita l “on the same basis as any

other physician app lying for med ical staff appointment and clin ical privileges.”

{¶4} On September 26, 2003, Dr. Lowrey signed a Consent and Re lease of

App licant and reapp lied for Med ical Staff privileges on October 2, 2003.

{¶5} On March 3, 2004, Dr. Dominquez advised Dr. Lowrey that “the

Credentia ls Comm ittee has comp leted its review for appo intment and privileges and

has

forwarded a

recommendation

to

the Medical Executive Committee not

recommend ing emp loyment and privileges.”

{¶6} On March 18, 2004, Dr. Lowrey was sent a Not ice of Adverse

Recommendation.

{¶7} On March 23, 2004, Dr. Lowrey’s counsel questioned the basis of the

Credentials Committee’s recommendation to not grant privileges to Dr. Lowrey and on

April 12, 2004, Dr. Lowrey requested a hearing to take place after June 12, 2004,

relating to the Credential Committee’s recommendation to not grant medical staff

privileges.

{¶8} On April 21, 2004, Mina Ubbing, President and CEO of the Hospital,

advised Dr. Lowrey by certified mail that the requested hearing was scheduled to take

place June 15 – 18, 2004. Dr. Lowrey’s counsel requested a continuance of the hearing,

which was rescheduled to August 23 – 27, 2004.

{¶9} On August 18, 2004, Dr. Lowrey submitted written notice withdrawing his

application and cancelling the August 23 – 27, 2004 hearing.

Fairfield County, Case No. 08 CA 85

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{¶10} In the nine months following the time Dr. Lowrey withdrew his staff

privileges application and cancelled the August 23 – 27, 2004 hearing, he filed four

separate lawsuits against Fairfield Medical Center.

{¶11} The case at issue before this Court is the third and only remaining of these

four lawsuits.

{¶12} In the litigation below, Dr. Lowrey sought discovery of certain peer review

materials, to which the Hospital asserted the peer review privilege and filed a Motion for

Protective Order based on R.C. §2305.252.

{¶13} On May 30, 2006, the trial court issued a Protective Order, which

remained in place throughout the litigation.

{¶14} Prior to trial, on August 29, 2008, the Hospital filed a Motion in Limine

based on the peer review privilege.

{¶15} On September 23, 2008, the date of the scheduled jury trial, the parties

submitted an Agreed Entry Continuing Trial, signed by the trial court and journalized on

September 26, 2008, wherein the parties agreed as follows:

{¶16} “The Court should reconsider Defendant’s prior Motion for Summary

Judgment if the Court determines that there has not been a waiver of the peer review

privilege of R.C. §2305.252. The Court hereby continues the trial of this matter until a

decision is reached on the admissibility of said peer review documents.”

{¶17} On October 28, 2008, the Court sustained the Hospital’s Motion in Limine

based on R.C. §2305.252, and on October 29, 2008 issued the following Entry:

{¶18} “Upon consideration of this Court’s ruling in its Entry filed on October 28,

2008 and pursuant to this Court’s Entry of September 26, 2008, the parties are hereby

Fairfield County, Case No. 08 CA 85

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ordered to submit Memorandum fully briefing the issue(s) to be considered by this Court

[i.e., whether summary judgment should be granted on the two remaining counts] on or

before November 17, 2008.”

{¶19} In Plaintiff’s Memoranda Contra

to

the Hospital’s Motion

for

Reconsideration submitted pursuant to the Court’s October 29, 2008 Entry, Dr. Lowrey

did not contest the Hospital’s Motion for Reconsideration of the ruling on Count One,

only contesting the Entry as to Count Six.

{¶20} On December 3, 2008, after consideration of the Hospital’s Motion for

Reconsideration and Plaintiff’s Memorandum Contra, the trial court sustained the

Hospital’s Motion for Summary Judgment and dismissed remaining Counts One and

Six.

{¶21} Appellant now appeals, assigning the following errors for review:

ASSIGNMENTS OF ERROR

{¶22} “I. THE TRIAL COURT ERRED IN RECONSIDERING AND GRANTING

SUMMARY JUDGMENT AS TO COUNT SIX OF DR. LOWREY’S COMPLAINT.

{¶23} “II. THE TRIAL COURT ERRED IN RECONSIDERING AND GRANTING

DEFENDANT’S MOTION FOR SUMMARY JUDGMENT AS TO COUNT ONE OF

APPELLANT’S COMPLAINT.

{¶24} “III. THE TRIAL COURT ERRED IN GRANTING DEFENDANT’S MOTION

IN LIMINE AS TO CERTAIN PEER REVIEW MATERIALS DUE TO THE FACT THAT

PRIVILEGE WAS WAIVED IN THE INSTANT CASE.”

{¶25} Appellant has failed to comply with Local App.R. 4(A) which requires

appellant to attach to his brief a copy of the judgment entry appealed from. Although

Fairfield County, Case No. 08 CA 85

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failure to comply with these rules is failure to prosecute for which dismissal may be

entered sua sponte, we decline to dismiss on procedural grounds and proceed to

address the merits of this appeal.

{¶26} For clarity and ease of analysis, we shall address Appellant’s assignments

of error out order.

III.

{¶27} In his third assignment of error, Appellant argues that the trial court erred

in granting defendant’s motion in limine as to certain peer review materials. We

disagree.

{¶28} Revised Code §2305.252 and §2305.253 set forth the confidentiality of

records and proceedings in the peer review process. R.C. §2305.252 provides an

umbrella of protection to information which is collected and maintained by a peer review

committee during a peer review process. R.C. §2305.252 addresses the confidentiality

of peer review committee proceedings and provides in pertinent part as follows:

{¶29} “Proceedings and records within the scope of a peer review committee of

a health care entity shall be held in confidence and shall not be subject to discovery or

introduction in evidence in any civil action against a health care entity or health care

provider, including both individuals who provide health care and entities that provide

health care, arising out of matters that are the subject of evaluation and review by the

peer review committee. No individual who attends a meeting of a peer review

committee, serves as a member of a peer review committee, works for or on behalf of a

peer review committee, or provides information to a peer review committee shall be

permitted or required to testify in any civil action as to any evidence or other matters

Fairfield County, Case No. 08 CA 85

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produced or presented during the proceedings of the peer review committee or as to

any finding, recommendation, evaluation, opinion, or other action of the committee or a

member thereof. Information, documents, or records otherwise available from original

sources are not to be construed as being unavailable for discovery or for use in any civil

action merely because they were produced or presented during proceedings of a peer

review committee, but the information, documents, or records are available only from

the original sources and cannot be obtained from the peer review committee’s

proceedings or records. An individual who testifies before a peer review committee,

serves as a representative of a peer review committee, serves as a member of a peer

review committee, works for or on behalf of a peer review committee, or provides

information to a peer review committee shall not be prevented from testifying as to

matters within the individual’s knowledge, but the individual cannot be asked about the

individual’s testimony before the peer review committee, information the individual

provided to the peer review committee, or any opinion the individual formed as a result

of the peer review committee’s activities. An order by a court to produce for discovery or

for use at trial the proceedings or records described in this section is a final order.”

{¶30} R.C. §2305.25(E)(1) defines “peer review committee” in part as follows:

{¶31} “ ‘Peer review committee’ means a utilization review committee, quality

assessment committee, performance improvement committee, tissue committee,

credentialing committee, or other committee that does either of the following:

{¶32} “(a) Conducts professional credentialing or quality review activities

involving the competence of, professional conduct of, or quality of care provided by

Fairfield County, Case No. 08 CA 85

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health care providers, including both individuals who provide health care and entities

that provide health care;

{¶33} “(b) Conducts any other attendant hearing process initiated as a result of a

peer review committee’s recommendations or actions….”

{¶34} The language in R.C. §2305.252, “manifests the legislature’s clear intent

to provide a complete shield to the discovery of any information used in the course of a

peer review committee’s proceedings.” Tenan v. Huston, 165 Ohio App.3d 185, 2006-

Ohio-131, 845 N.E.2d 549, at paragraph 23. However, the purpose of the statute is not

to hinder lawsuits, but to provide limited protection to individuals who provide

information to review committees or boards, thereby encouraging a free flow of

information without fear of reprisal in the form of civil liability. Browning v. Burt (1993),

66 Ohio St.3d 544, 562, 613 N.E.2d 993.

{¶35} A party asserting the privilege set forth in R.C. §2305.252 has the burden

of establishing that the privilege is applicable. See, e.g., Waldmann v. Waldmann

(1976), 48 Ohio St.2d 176, 178, 358 N.E.2d 521; Svoboda v. Clear Channel Commun.,

Inc., 156 Ohio App.3d 307, 2004-Ohio-894, 805 N.E.2d 559; Perfection Corp. v.

Travelers Cas. & Sur., 153 Ohio App.3d 28, 2003-Ohio-2750, 790 N.E.2d 817.

{¶36} Generally, the review of a trial court’s discovery order is pursuant to an

abuse of discretion standard; but when the trial court’s order contains an error of law in

misconstruing or misapplying the law, then the appellate court reviews the matter de

novo. Quinton v. MedCentral Health Sys., Richland App. No. 2006CA0009, 2006-Ohio-

4238, 2006 WL 2349548, at paragraph 13. The issue of the confidentiality of information

pursuant to R.C. §2305.252 is one of law. Id. See also, Smith v. Manor Care of Canton,

Fairfield County, Case No. 08 CA 85

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Inc., Stark App. Nos. 2005-CA-00100, 2005-CA-00160, 2005-CA-00162, and 2005-

CA00174, 2006-Ohio-1182; Huntsman v. Aultman Hospital, Stark App. Nos.

2004CA00124 and 2004CA00142, 2005-Ohio-1482, 160 Ohio App.3d 196, 826 N.E.2d

384.

{¶37} Specifically, Appellant argues that the Hospital waived the peer review

privilege by failing to object to, move to strike or otherwise respond to Appellant’s

Motion of Extension of Time which was filed under seal and which attached certain peer

review documents. Appellant argues that once the trial court had reviewed the

privileged documents, such privilege was waived.

{¶38} Upon review, we find Appellant’s waiver argument unpersuasive. We do

not find that Appellee’s alleged inaction in not objecting to the peer review documents

Appellant attached to his Motion for Extension of Time, which was filed under seal,

resulted in a waiver of the peer review privilege.

{¶39} The trial court in this matter had granted a protective order which

prohibited Appellant from seeking “any evidence or other matters produced or

presented during the proceedings of the peer review committee or as to any finding,

recommendation, evaluation, opinion, or other action of the committee or member

thereof.” The trial court never modified or withdrew such protective order. There was

no reason for Appellee to object to the documents which Appellant attached to his

Motion as the trial court had already granted a protective order as to same.

{¶40} Ohio courts have recognized that such a broad concept of waiver would

negate the purpose of the peer review confidentiality statute. Atkins v. Walker (1981), 3

Ohio App.3d 427, 445 N.E.2d 1132.

Fairfield County, Case No. 08 CA 85

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{¶41} Based on the foregoing, we find Appellant’s waiver argument not well-

taken and hereby overrule same.

{¶42} Appellant’s third assignment of error is denied.

I., II.

{¶43} In his first and second assignments of error, Appellant claims the trial

court erred in granting summary judgment in favor of Appellee as to Counts One and

Six of his Complaint. We disagree.

“Summary Judgment Standard”

{¶44} Summary judgment proceedings present the appellate court with the

unique opportunity of reviewing the evidence in the same manner as the trial court.

Smiddy v. The Wedding Party, Inc. (1987), 30 Ohio St.3d 35, 36. Civ.R. 56(C) provides,

in pertinent part:

{¶45} “Summary

judgment shall be rendered

forthwith

if

the pleadings,

depositions, answers to interrogatories, written admissions, affidavits, transcripts of

evidence in the pending case, and written stipulations of fact, if any, timely filed in the

action, show that there is no genuine issue as to any material fact and that the moving

party is entitled to judgment as a matter of law. * * * A summary judgment shall not be

rendered unless it appears from such evidence or stipulation and only therefrom, that

reasonable minds can come to but one conclusion and that conclusion is adverse to the

party against whom the motion for summary judgment is made, such party being

entitled to have the evidence or stipulation construed most strongly in his favor.”

{¶46} Pursuant to the above rule, a trial court may not enter a summary

judgment if it appears a material fact is genuinely disputed. The party moving for

Fairfield County, Case No. 08 CA 85

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summary judgment bears the initial burden of informing the trial court of the basis for its

motion and identifying those portions of the record that demonstrate the absence of a

genuine issue of material fact. The moving party may not make a conclusory assertion

that the non-moving party has no evidence to prove its case. The moving party must

specifically point to some evidence which demonstrates the non-moving party cannot

support its claim. If the moving party satisfies this requirement, the burden shifts to the

non-moving party to set forth specific facts demonstrating there is a genuine issue of

material fact for trial. Vahila v. Hall, 77 Ohio St.3d 421, 429, 1997-Ohio-259, citing

Dresher v. Burt, 75 Ohio St.3d 280, 1996-Ohio-107.

{¶47} It is based upon this standard that we review Appellant’s assignments of

error.

{¶48} Upon review, we find that the issues in this case are governed by the

Supreme Court’s decision in Nemazee v. Mt. Sinai Medical Ctr. (1990), 56 Ohio St.3d

109, where the syllabus states:

{¶49} “A physician in a private hospital whose employment and/or hospital

privileges have been terminated must exhaust all internal administrative remedies prior

to seeking judicial review.”

{¶50} In the instant case, Appellant, like the doctor in Nemazee, originally

requested a hearing under the hospital’s due process policy to contest the termination

or non-renewal of his privileges, but later withdrew that request and brought suit for

breach of contract. Id. at 110.

{¶51} The Supreme Court held that the doctor was required to exhaust the

administrative remedies provided in his employment contract prior to initiating suit. After

Fairfield County, Case No. 08 CA 85

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analyzing the general doctrine of exhaustion of remedies from administrative agencies,

the Court noted that the same principle applied to decisions on staff competence under

administrative due process procedures in hospitals, stating:

{¶52} “[t]he great weight of case authority in the United States is that a board of

trustees of a private hospital has the authority to appoint and remove members of the

medical staff of the hospital and to exclude members of the medical profession in its

discretion from practicing in the hospital.” ***

{¶53} Based upon Nemazee, supra, we find that Appellant failed to exhaust all

internal administrative remedies provided by the Hospital prior to seeking judicial

review. “The purpose of the exhaustion doctrine is to afford the hospital the ability to

correct its own errors; to provide a trial court with an adequate factual record upon

which to make an informed decision as established by the expert testimony of the

medical staff; and to promote judicial economy through the resolution of these disputes

without the premature need for judicial intervention.” O’Neill v. St. Luke’s Medical

Center, (1996) Cuyahoga App. No. 70372.

{¶54} Additionally, we find that Appellant failed to produce any evidence in

support of Counts One and Six of his Complaint.

Fairfield County, Case No. 08 CA 85

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{¶55} Appellant’s first and second assignments of error are denied.

{¶56} For the foregoing reasons, the judgment of the Court of Common Pleas of

Fairfield County, Ohio, is hereby affirmed.

By: W ise, J.

Hoffman, P. J., concurs in part and dissents in part.

Edwards, J., concurs separately.

JWW/d 721

___________________________________

___________________________________

___________________________________

JUDGES

Fairfield County, Case No. 08 CA 85

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Hoffman, P.J., concurring in part and dissenting in part

{¶57} I concur

in

the majority’s analysis and disposition of Appellant’s

Assignments of Error I and III. W ith respect to the first assignment, I reject Appellant’s

argument exhaustion of administrative remedies was not necessary because

Appellant’s claim was for breach of the Settlement Agreement. Because the Settlement

Agreement required Appellant’s application for privileges to be considered on the same

basis as the application of any other physician, and all such other applications were

subject to administrative review, as set forth in the Consent and Release of Applicant

executed by Appellant, I find Appellant was also required to exhaust all administrative

remedies before initiating his lawsuit with respect to Count Six.

{¶58} I respectfully dissent from the majority’s disposition of Appellant’s

Assignment of Error II. Unlike Count Six, I do not find Count One subject to the

exhaustion of administrative remedies requirement.

{¶59} I disagree with Appellees’ assertion Appellant’s failure to specifically

address Count One in his reply to Appellees’ Motion for Reconsideration of the trial

court’s previous denial of summary judgment waives his right to raise the issue in this

appeal. Appellant’s initial reply to Appellees’ original summary judgment motion must

still be considered.

{¶60} Appellant states in his Affidavit, his contact information was not shared

with his patients in breach of the Settlement Agreement.1 While Appellees have

1 In the absence of a motion of strike Appellant’s Affidavit for lack of personal knowledge
or hearsay, such averment should be accepted when offered in defense of a motion for
summary judgment. Had a motion to strike been filed, Appellant would have had the
opportunity to cure any deficiency with additional affidavits from his patients. That is not

Fairfield County, Case No. 08 CA 85

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submitted the Affidavits of Connie Fisher and Kevin Schmelzer to prove otherwise, a

genuine issue of this material fact remains in dispute. As such, I would sustain

Appellant’s Assignment of Error II.

________________________________
HON. W ILLIAM B. HOFFMAN

to say a motion to strike the movant’s affidavit based upon lack of personal knowledge
or hearsay is necessary to defeat summary judgment.

Fairfield County, Case No. 08 CA 85

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EDWARDS, J., CONCURRING OPINION

{¶61} I concur with the analysis and disposition of this case by Judge W ise with

one exception.

{¶62} The exception is that I do not agree that Count I is subject to the

exhaustion of administrative remedies requirement. However, this disagreement does

not lead to a different disposition of the second assignment of error. This is because I

find that appellant waived his right to raise the second assignment of error on appeal by

not addressing the issue in his reply to appellee’s Motion for Reconsideration of the trial

court’s previous denial of summary judgment.

JAE/rmn

______________________________

Judge Julie A. Edwards

CHARLES LOWREY, M.D.

Plaintiff-Appellant

-vs-

FAIRFIELD MEDICAL CENTER, ET AL.

Defendant-Appellees

:
:
:
:
:
:
:
:
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JUDGMENT ENTRY

Case No. 08 CA 85

Fairfield County, Case No. 08 CA 85

17

IN THE COURT OF APPEALS FOR FAIRFIELD COUNTY, OHIO
FIFTH APPELLATE DISTRICT

For the reasons stated in our accompanying Memorandum-Opinion, the

judgment of the Court of Common Pleas of Fairfield County, Ohio, is affirmed.

Costs assessed to Appellant.

___________________________________

___________________________________

___________________________________

JUDGES

Lurie v. Mid-Atl. Permanente Med. Group (Full Text)

Lurie v. Mid-Atl. Permanente Med. Group (Full Text)

Case 1:06-cv-01386-RCL Document 84 Filed 08/09/10 Page 1 of 41

DEAN KEVIN LURIE, M.D.

Plaintiff,

v.

UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF COLUMBIA
____________________________________
)
)
)
)
)
) Civil Action No. 06-01386 (RCL)
)

)
MID-ATLANTIC PERMANENTE
)
)

MEDICAL GROUP, P.C.

)
Defendant.

____________________________________)

MEMORANDUM OPINION

I.

Introduction

The case concerns an employment dispute between plaintiff Dr. Dean Kevin Lurie, a

surgeon, and his former employer defendant Mid-Atlantic Permanente Medical Group. After

many years of working for defendant, plaintiff was terminated for allegedly falsifying his time

sheets and his history of disciplinary problems, reasons plaintiff claims are a mere pretext for

disposing of an old employee who challenged unprofessional conduct at his workplace. In

addition to a number of common law claims for breach of contract, tortious interference, and

wrongful discharge, plaintiff alleges violations of the Age Discrimination in Employment Act

(ADEA) and the Employee Retirement Income Security Act (ERISA). Defendant filed a

counterclaim seeking recovery for breach of contract, fraud, negligent misrepresentation, and

unjust enrichment. Currently, before the Court are defendant’s motion [78] to strike plaintiff’s

statement of material fact, defendant’s motion [68] for summary judgment and plaintiff’s motion

[69] for summary judgment on the counterclaim. Based on the following considerations, the

Court will DENY defendant’s motion to strike and GRANT defendant’s motion for summary

1

Case 1:06-cv-01386-RCL Document 84 Filed 08/09/10 Page 2 of 41

judgment. The Court does not reach plaintiff’s motion for summary judgment, because the Court

lacks jurisdiction over defendant’s counterclaim. Therefore, the Court will DISMISS

defendant’s counterclaim on jurisdictional grounds.

II.

Factual Background

Plaintiff is a vascular surgeon residing in the District of Columbia. (Pl.’s Verified

Compl. [72-3] ¶ 5.) Defendant is a professional corporation with its principal place of business

in Maryland that employs physicians who provide medical services to members of the Kaiser

Foundation Health Plan of the Mid-Atlantic States. (Id. ¶ 6; Cahill Aff. [68-3] ¶ 3.) Plaintiff’s

employment with defendant began in 1998. In addition to substantive terms of employment,

plaintiff’s job offer letter included a provision mandating that plaintiff abide by defendant’s

“policies, rules and regulations.” (Pl.’s Ex. 2 [69-4] at 2.) Plaintiff signed the letter and

commenced working for defendant as a surgeon in the District of Columbia and its Maryland

suburbs. (Id. at 3; Cahill Aff. [68-3] ¶ 5.)

As part of his duties with defendant, plaintiff was assigned to treat patients at various

local hospitals. 1

(Lurie Dep. [68-4] at 67:13.) While working at the Washington Hospital Center

(WHC), plaintiff came into conflict with his colleagues over concerns about safety and quality of

care. (Id. at 107:18–108:13, 115:13–116:21.) When he raised his concerns with his superiors, he

received some hostile responses. (Def.’s Ex. 3 [68-5] at 2–3; Def.’s Ex. 5 [68-7] at 2.)

Citing plaintiff’s troubled relations with the surgical residents, the head of surgery

requested and obtained plaintiff’s reassignment in 2001. (Def.’s Ex. 4 [68-6] at 2; Lurie Dep.

[68-4] at 83:7–11.) Official admonitions from defendant followed, and when plaintiff was

1 Although defendant maintained outpatient clinics like the Largo Medical Center, it also needed to be able to see
patients at hospitals. (See Lurie Dep. at 54:8–15.) Consequently, its physicians were assigned to independent,
partner hospitals like the Washington Hospital Center where they could treat Kaiser patients. (See Lurie Dep. [68-4]
at 52:3–54:21.)

2

Case 1:06-cv-01386-RCL Document 84 Filed 08/09/10 Page 3 of 41

reassigned to WHC two years later, the head of surgery complained about his behavior once

again. (Def.’s Ex. 5 [68-7] at 2; Lurie Dep. [68-4] at 102:1–13; Def.’s Ex. 6 [68-8] at 3.) In late

2003, plaintiff was suspended with pay and an investigation was conducted of his conduct.

(Lurie Dep. [68-4] 152:11–153:12.)

Not long after this last round of disciplinary action, plaintiff was transferred to

defendant’s Largo, Maryland medical center. (Lurie Dep. [68-4] at 118:15–120:10.) When

plaintiff first arrived, he felt pressured to see many double-booked patients. (Id. at 300:7–10.)

Plaintiff’s colleagues told him that, at the Largo Center, these extra patients were handled by

establishing evening clinics or ghost clinics. (Id. at 300:10–15.) The phrase “ghost clinic” is

defendant’s terminology for a billing method utilized by certain physicians employed by

defendant. (Mem. in Supp. of Def.’s Mot. for Summ. J. [68-2] at 5.) Physicians who had many

sessions double booked during the day would include hand-written addendums with their time

sheets that specified hours worked during the evening. (Lurie Dep. [68-4] at 284:16–286:12,

300:4–18, 301:15–302:6.) Physicians could thereby be compensated for the extra patients seen

during regular hours. (Id. at 302:4–12.) In reality, no patients were actually treated in the

evening, thus the expression, ghost clinic. (Id. at 289:5–290:8.)

Defendant was not alone in making use of ghost clinics. Dr. Cohen, an orthopedist, and

Dr. McCanty, a urologist, billed for double-books in the same manner as plaintiff. (Cohen Dep.

[72–9] at 18:12–19:14; McCanty Dep. [72-14] at 25:5–21.) Additionally, Dr. Krolik, a surgeon

who worked with plaintiff, established ghost clinics on three occasions in 2004. (Cahill Aff. [68-

3] ¶ 14.) None of these physicians were subject to disciplinary action as a result of their billing

practices. (Pl.’s Opp’n [72] at 16.) Although plaintiff followed the example and advice of his

fellow doctors in creating ghost clinics, (Lurie Dep. [68-4] at 300:4–301:8, 302:19–303:11), his

3

Case 1:06-cv-01386-RCL Document 84 Filed 08/09/10 Page 4 of 41

manager gave a negative response when he asked about receiving extra compensation for days

when doctors were overbooked. (Manning Dep. [68-27] at 99:2–102:10.)

Eventually, plaintiff’s use of ghost clinics came to the attention of a compliance officer

named Ann Cahill. (Cahill Aff. [68-3] ¶¶ 2, 12.) She launched an investigation of plaintiff’s

time sheets and discovered that he was reporting more hours than the other doctors on

defendant’s payroll. (Id. ¶ 12.) Indeed, Cahill found that plaintiff was the only physician in the

medical group to have created ghost clinics in the preceding six month period. (See id. at 15.)

Based on Cahill’s finding as well as plaintiff’s poor discipline history, defendant terminated

plaintiff during an October 2005 meeting at its Maryland headquarters. (Id.) At that time,

plaintiff was forty-eight years old. (Compl. [1] ¶ 24.)

While at the Largo facility, defendant had arranged to conduct a clinical trial of a new

surgical device. (See Lurie Dep. [74-1] at 240:2–12.) To govern the clinical trial, plaintiff,

defendant, and the device company (Graftcath) signed a document outlining the terms of their

relationship and naming plaintiff principal investigator. (Def.’s Ex. 18. [70] at 2.) When

plaintiff was terminated, he was unable to continue serving as principal investigator. (Pl.’s

Verified Compl. [72-3] ¶ 38.)

After his removal, plaintiff opened a private medical practice. (Pl.’s Verified Compl.

[72-3] ¶ 19.) Though he applied for membership in defendant’s network of outside providers, he

was rejected. (Id.) Efforts to develop his new practice have been hindered by his reduced access

to Kaiser Health Group patients, (see Lurie Dep. [68-4] at 354:19–355:11), some of whom may

have been dissuaded by defendant from seeking treatment with plaintiff despite his status as their

preferred surgeon. (See Pl.’s Ex. 3 [72-5] ¶ 5; Pl.’s Ex. 4 [72-6] ¶ 5.)

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III. Defendant’s Motion to Strike

Local rule 7(h) requires that a party opposing summary judgment include a “separate

concise statement of genuine issues setting forth all material facts as to which it is contended

there exists a genuine issue to be litigated, which shall include references to the parts of the

record relied on to support the statement.” LCvR 7(h). The purpose of the rule is to aid courts in

deciding motions for summary judgment by refining the record to focus on disputed factual

issues. Burke v. Gould, 286 F.3d 513, 517 (D.C. Cir. 2002). In interpreting the rule, the Circuit

Court has prescribed caution, warning of the drastic consequences of striking a party’s statement

of fact. Id. at 517. The remedy should be reserved for those cases involving “egregious

conduct.” Id.

Defendant contends that plaintiff’s statement of material fact violates local rule 7(h) and

should be stricken. In support of its motion, defendant argues that plaintiff’s statement is

overlong at 117 pages, is suffused with argument, and fails to squarely address defendant’s

statements of fact. (Def.’s Mem. in Supp. of Mot. to Strike [78-1] at 2, 4, 11.)

Although plaintiff’s statement needlessly extends to 117 pages, it cites to the record and

rightfully does not contain legal argument. (See, e.g., id. ¶¶ 14, 21, 22, 87, 123.) For example,

defendant’s statement of material fact affirms, “The letter was sharply critical of WHC’s surgery

department chairman, John Kirkpatrick in particular.” (Def.’s Local Rule 7(h) Statement [68-28]

¶ 14.) In his own statement, plaintiff denies this assertion then launches into a four page

description of hospital policy on official complaints and the Code of Ethics of the American

Medical Association. (Pl.’s Statement [72-1] ¶ 14.)

While the plaintiff’s statement is inappropriately long and evasive, the Court cannot say

that a statement of fact which otherwise comports with local rule 7(h) by citing to the record,

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separately responding to each of defendant’s statements, and refraining from legal argument is

egregious and ought to be stricken. Compare Chambliss v. Nat’l R.R. Passenger Corp., No. 05-

2490, 2007 WL 581900, at *2 (D.D.C. 2007) (granting a motion to strike where plaintiff’s

statement did not properly cite the record, interspersed legal argument, and did not correspond to

paragraphs in defendant’s statement). Accordingly, defendant’s motion [78] to strike plaintiff’s

statement [72-1] is denied.

IV. Defendant’s Motion for Summary Judgment

A. Summary Judgment Standard

Generally, summary judgment should be granted only if the moving party has shown that

there are no genuine issues of material fact and that the moving party is entitled to judgment as a

matter of law. FED.R.CIV.P. 56; Celotex Corp. v. Catrett, 477 U.S. 317, 322 (1986); Waterhouse

v. District of Columbia, 298 F.3d 989, 991 (D.C.Cir.2002). A genuine issue of material fact

exists if the evidence, when viewed in a light most favorable to the non-moving party, “is such

that a reasonable jury could return a verdict for the non-moving party.” Anderson v. Liberty

Lobby, Inc., 477 U.S. 242, 248 (1986). In determining whether a genuine issue of material fact

exists, the Court must view all facts in the light most favorable to the non-moving party. See

Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 587 (1986). The non-moving

party’s opposition, however, must consist of more than mere unsupported allegations or denials

and must be supported by affidavits or other competent evidence setting forth specific facts

showing that there is a genuine issue for trial. FED.R.CIV.P. 56(e); see Celotex Corp., 477 U.S.

at 324. At the summary judgment stage, a judge may not make credibility determinations, as that

is the function of a jury. George v. Leavitt, 407 F.3d 405, 413 (D.C. Cir.2005).

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B. ADEA

The Age Discrimination in Employment Act (ADEA) forbids an employer from

firing an employee on the basis of his age. 29 U.S.C. § 623(a)(1) (2006). The Circuit Court has

clearly articulated the standard to be used in evaluating motions for summary judgment in

employment discrimination disputes:

[I]n considering an employer’s motion for summary judgment or judgment as a
matter of law in those circumstances, the district court must resolve one central
question: Has the employee produced sufficient evidence for a reasonable jury to
find that the employer’s asserted non-discriminatory reason was not the actual
reason and that the employer intentionally discriminated against the employee on
the basis of race, color, religion, sex, or national origin?

Brady v. Office of the Sergeant of Arms, 520 F.3d 490, 494 (D.C. Cir. 2008) (citing St. Mary’s

Honor Ctr. v. Hicks, 509 U.S. 502, 507–08, 511 (1993), and U.S. Postal Serv. Bd. of Governors

v. Aiken, 460 U.S. 711, 714–716 (1983)). 2

Subsequent to Brady, the Supreme Court further focused the ADEA standard. It held, “A

plaintiff bringing a disparate-treatment claim pursuant to the ADEA must prove, by a

preponderance of the evidence, that age was the ‘but-for’ cause of the challenged adverse

employment action.” Gross v. FBL Fin. Servs., Inc., 129 S. Ct. 2343, 2352 (2009). Put

differently, it is not enough that age was one motivating factor in an adverse employment action;

rather, it must be the case that the adverse action would not have occurred in the absence of age

as a consideration. See id. at 2350.

Therefore, the Court must decide whether sufficient evidence exists for a reasonable juror

to find that defendant’s proffered reasons for terminating plaintiff mask discriminatory intent that

rendered age the but-for cause of plaintiff’s termination. Evidence of pretext may include

2 Brady does not expressly address age discrimination claims. However, this Court and the other courts of this
district have regularly extended Brady’s methodology to claims under the ADEA. Chappell-Johnson v. Blair, 574
F. Supp. 2d 87, 96 n.9 (D. D.C. 2008), aff’d, 358 Fed. App’x 200 (D.C. Cir. 2009). Hence, the Court does not
hesitate in applying Brady to the present case.

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variant treatment of similarly situated employees, discriminatory statements by decision makers,

and irregularities in the stated reasons for the adverse employment decision. Brady, 520 F.3d at

495 & n.3. However, discrimination will not be inferred from the fact that defendant’s reasons

prove unfounded so long as they are held reasonably and in good faith. Brady, 520 F.3d at 495.

Similarly, an inference of discrimination should not be drawn from disparate treatment of

comparable employees unless “all of the relevant aspects of [a plaintiff’s] employment situation

[are] ‘nearly identical’” to those of the comparator. Neuren v. Adduci, Mastriani, Meeks, &

Schill, 43 F.3d 1507, 1514 (D.C. Cir. 1995).

In the instant case, defendant asserts that plaintiff was fired for falsifying his time sheets

and for his long history of disciplinary problems. (Mem. in Supp. [68-2] at 5.) In order to

demonstrate that defendant’s stated reasons were only a pretext for age discrimination, plaintiff

pursues roughly five distinct lines of argument: (1) plaintiff was replaced by a less qualified,

younger physician; (2) plaintiff completed his time sheets consistent with company practice and

was the only physician disciplined for so doing; (3) plaintiff’s disciplinary history was

undeserved and a contrived, post hoc justification for his termination; (4) defendant’s managers

were aware that the defendant stood to reap financial benefits from terminating older physicians

like plaintiff; and (5) defendant’s managers made depreciatory remarks about plaintiff’s age.

(Pl.’s Opp’n to Def.’s Mot. for Summ. J. [72] at 13–14, 16–18.)

1. Plaintiff was not “replaced” by a younger doctor

Plaintiff claims that Dr. Aryavand was hired as his more youthful but less meritorious

replacement. Specifically, plaintiff alleges that Dr. Aryavand was offered a job only one day

before defendant began the investigation which led to plaintiff’s termination. (See Pl.’s Ex. 37

[69-39] at 2; Cahill Aff. [68-3] ¶ 18.) Dr. Aryavand was thirty-eight at the time he was hired

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while plaintiff was forty-eight at the time he was fired. (Aryavand Dep. [72-7] at 22:5–8;

Compl. [1] ¶ 24.) Both plaintiff and Dr. Aryavand were vascular surgeons. (Pl.’s Verified

Compl. [72-3] ¶ 12; Aryavand Dep. [72-7] at 14:9–12.)

However, plaintiff’s evidence provides little basis for a jury to infer that Dr. Aryavand

was hired as plaintiff’s replacement, much less that plaintiff suffered discrimination thereby.

After Dr. Aryavand was hired, he and plaintiff worked at different facilities; whereas plaintiff

was employed at defendant’s Largo, Maryland center, Dr. Aryavand worked for defendant in

Kensington, Maryland and in Washington DC. (Lurie Dep. [68-4] at 120:3–10; Aryavand Dep.

[72-7] at 22:11–23:16, 46:13–16.) Furthermore, Dr. Aryavand possessed qualifications that

plaintiff lacked; he was a fellowship-trained vascular surgeon while plaintiff did not have such

training. (Aryavand Dep. [72-7] at 12:17–21; Lurie Dep. [68-4] at 14:14–18.) Finally, in

regards to the timing of personnel decisions, the alleged connection between defendant’s offer of

employment to Dr. Aryavand and its decision to investigate plaintiff is terribly attenuated. Other

than pointing out the conjunction, plaintiff furnishes no evidence from which a reasonable juror

could find that the timing of defendant’s actions was anything more than a coincidence.

2. Defendant acted in good faith in terminating plaintiff for his timesheet
practices

Plaintiff alleges that his timesheet practices were in accord with defendant’s policies and

that he alone was punished for the common practice of creating so-called ghost clinics. In

support of his contentions, plaintiff claims that a document obtained from defendant entitled

“MAPMG Pay Practices, July 2005” [72-34] verifies that defendant sanctioned the use of ghost

clinics. The document, however, cannot be fairly read to support plaintiff’s position; nothing

indicates that physicians could be paid for multiple double-books during the day by charging for

dummy patients treated in the evening. (See Pl.’s Ex. 32 [72-34].) For instance, where the report

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refers to payments for “extra sessions,” it appears to be indicating medical work actually

performed after-hours such as “urgent cases in late afternoon or evening,” not services for

fictitious evening patients. (Id. at 2.) In sum, plaintiff’s conclusory characterization of this

document would not permit a jury to find that ghost clinics were authorized by defendant.

Next, plaintiff argues that establishing ghost clinics was a common practice in which

defendant’s managers acquiesced. After arriving at defendant’s Largo, Maryland medical center,

plaintiff’s colleagues told him that these extra patients were handled by establishing evening

clinics (ghost clinics). (Id. at 300:10–15.) Despite the reassurances of his fellow surgeons,

plaintiff remained hesitant and prompted the head nurse Sharon Stewart to seek authorization

from her manager Ms. Williams who then consulted her manager Mr. Labash. (Id. at 301:2–11.)

Afterwards, Ms. Lawrence informed plaintiff that her managers had given instructions to operate

ghost clinics. (Id. at 301:12–15.) Note however, that as a surgeon, plaintiff’s immediate

supervisors were Dr. Manning and Dr. Schwartz. (Id. at 40:1–4, 304:6–10.) Though neither Dr.

Manning nor Dr. Schwartz ever expressly authorized the use of ghost clinics, plaintiff believed

that they tacitly endorsed the practice. (See id. at 303:18–306:6). However, neither Dr. Manning

nor Dr. Schwartz, plaintiff’s immediate supervisors, ever expressly authorized the use of ghost

clinics. (See id. at 303:18–306:6).

While a jury could infer that if plaintiff was not violating company policy, that

defendant’s stated reasons for terminating plaintiff were pretextual, the record does not support

that conclusion. The evidence that defendant approved of the use of ghost clinics addresses the

perception of plaintiff and his colleagues, rather than the understanding of his supervisors and

the managers involved in his termination. See George v. Leavitt, 407 F.3d 405, 415 (D.C. Cir.

2005) (stating that a defendant may prevail on summary judgment if there is no genuine issue as

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to whether the manager making the termination decision honestly and reasonably believed in

defendant’s reasons).

There is evidence that relevant managers did not share plaintiff’s belief about the

acceptability of ghost clinics. For example, when plaintiff asked his supervisor about receiving

additional payment for multiple double books, the matter was taken to a higher manager who

expressly rejected the idea. (Manning Dep. [68-27] at 99:2–100:5.) Whereas plaintiff’s

evidence goes to his belief in the propriety of ghost clinics and his understanding that his

supervisors’ acquiesced in the practice, the supervisors themselves rejected it.

More importantly, the managers participating in the investigation preceding defendant’s

termination, Traci Holsteen and Ann Cahill, did not accept the legitimacy of ghost clinics.

Holsteen was defendant’s Director of Regional Access Services. (Holsteen Aff. [68-16] ¶ 2.) In

June 2005, whilst conducting a “routine review of physician schedules,” Holsteen noticed that

evening sessions had been opened for plaintiff in which patients he had seen earlier in the day

were booked. (Id.) Subsequently, Holsteen sent an email to plaintiff’s supervisors, Dr. Manning

and Dr. Schwartz, expressing her concern at her findings. (Id. ¶ 3.) She wrote,

Dr. Lurie is the only surgeon that I am aware of that sees his double books during
the day and places them in an extra session in the evening. His timesheet will
reflect an additional four hours that was filled with one hour’s equivalent of
patients that were seen during his regular day. This is not the routine for our
approach to scheduling.

(Id. at 4.) Eventually, the matter was referred to Cahill. (Cahill Aff. [68-3] ¶¶ 2, 12.) After

reviewing plaintiff’s time sheets, Cahill recognized that plaintiff was reporting many more hours

than his fellow physicians. (Id. ¶ 12.) Further exploring company files, she found that no other

physician in 2004 or 2005 had created ghost clinics except for plaintiff’s surgical colleague Dr.

Krolik who created just three ghost clinics in 2004. (Id. ¶¶ 12, 14). Following Cahill’s

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investigation, defendant terminated plaintiff in October of 2005. (Id. ¶ 15.) By all appearances,

Holsteen and Cahill honestly and reasonably believed that plaintiff’s timesheets were improper.

Accordingly, no reasonable jury could infer discrimination from the time sheet evidence.

Plaintiff also maintains that while other physicians, including his surgical colleague Dr.

Krolik, created ghost clinics, only he was disciplined for doing so. He alleges his disparate

treatment is indicative of discrimination. Plaintiff is correct that evidence that similarly situated

employees were treated differently is proper fodder for an employment discrimination case.

Brady, 520 F.3d at 495. However, plaintiff’s long disciplinary history and the magnitude of his

use of ghost clinics serve to distinguish him from doctors who were not disciplined. 3

Doctors who used ghost clinics but were not punished include Dr. Cohen, an orthopedist,

Dr. McCanty, a urologist, and plaintiff’s surgical colleague Dr. Krolik. (Cohen Dep. [72–9] at

18:12–19:14; McCanty Dep. [72-14] at 25:5–21; Cahill Aff. [68-3] ¶ 14; Pl.’s Opp’n [72] at 16.)

Plaintiff can be distinguished from Dr. Cohen and Dr. McCanty as neither physician worked in

the department of surgery with plaintiff. (See Lurie Dep. [68-4] at 287:18–21, 38:13–15.)

Additionally, neither doctor is alleged to possess a comparable disciplinary record. As a fellow

surgeon, Dr. Krolik is a better candidate for comparison but still possesses significant differences

from plaintiff. For one, she used ghost clinics relatively little. (See Cahill Aff. [68-3] ¶ 14.)

From the beginning of 2004 to October 2005, Dr. Krolik recorded ghost clinics on three

occasions while plaintiff did so at least fourteen times during the same period. (Id.) What is

more, Dr. Krolik had a spotless record. (Id.) In contrast, plaintiff had often been in trouble with

the company, a fact that defendant considered in deciding to discharge him. (Cahill Aff. [68-3] ¶

15; see discussion infra Part IV.B.2.c) Given the different employment situations of the three

3 Comparators must be nearly identical to a plaintiff in all relevant aspects of their employment situation. Neuren,
43 F.3d at 1514.

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doctors, the Court should not infer discrimination from the fact that they were not similarly

punished for maintaining ghost clinics. See Childs-Pierce v. Util. Workers Union of Am., 383 F.

Supp. 2d 60, 74–75 (D.D.C. 2005) (refusing to find pretext where plaintiff had accumulated

record of deceit and insubordination while comparators had never been disciplined).

3. Defendant could have terminated plaintiff in good faith based on his
disciplinary history

Plaintiff’s third argument contests defendant’s appeal to past disciplinary incidents as a

reason for plaintiff’s termination. Evidence of falsehood and inconsistency vis-à-vis stated

reasons for termination may be used to infer discriminatory intent. Brady, 520 F.3d at 495 &

n.3. Plaintiff, however, fails to contest the existence of his disciplinary record and its use as a

basis for his firing.

Plaintiff drew the ire of company officials on several occasions. The history of plaintiff’s

troubles begins in 2001 when he was reassigned from WHC after the head of surgery there

complained about his behavior. (Def.’s Ex. 4 [68-6] at 2; Lurie Dep. [68-4] at 83:7–11.) In

response to this incident, defendant saw fit to officially warn plaintiff and admonish him about

his behavior. (See Def.’s Ex. 5 [68-7] at 2.) Two years later, plaintiff was reassigned to WHC,

but again the head of surgery complained about his behavior. (Lurie Dep. [68-4] at 102:1–13;

Def.’s Ex. 6 [68-8] at 3.) In late 2003, defendant suspended plaintiff with pay and an

investigation was conducted of his conduct. (Lurie Dep. [68-4] 152:11–153:12.) It also issued

him a reprimand letter and a Performance Improvement Plan. (See Def.’s Ex. 8 [68-10]; Def’s

Ex. 9 [68-11].) Afterwards, plaintiff kept encountering trouble with patients and co-workers

alike. (See, e.g., Def.’s Ex. 11 [68-13].)

Plaintiff responds by offering an alternate characterization of his time at the company,

one in which he plays the part of the white knight, victimized by defendant for insisting on high

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standards of professionalism. (See Pl.’s Opp’n [72] at 17.) Yet regardless of whether plaintiff’s

sanctions were fair or right, defendant could legitimately take plaintiff’s record into account in

making its decision to terminate plaintiff. It is enough that defendant honestly and reasonably

believed in the validity of its bases for terminating plaintiff. See George, 407 F.3d at 415.

Plaintiff also tries to show that defendant’s invocation of his disciplinary record was

pretextual by pointing to awards he received and improvements in his official evaluations. (Pl.’s

Opp’n [72] at 17.) Regardless of whether plaintiff received the accolades, defendant still could

have honestly and reasonably relied on defendant’s past troubles as a basis for his termination. It

may well have been foolish to terminate a surgeon as talented as plaintiff but that does not

demonstrate that defendant’s appeal to plaintiff’s disciplinary record was insincere.

Finally, plaintiff contests that his discipline record was part of the original justification

for his termination and declares that it was only asserted later to “ress [d]efendant’s case.”

(See Pl.’s Opp’n [72] at 16.) Plaintiff’s position, however, is based on a mischaracterization of

Cahill’s deposition testimony. (See Pl.’s Opp’n [72] at 16–17.) In his brief, plaintiff quotes in

isolation the following bit of the deposition record: “Q. Was there any other reason why he was

terminated? A. No.” (Cahill Dep. [72-8] at 156:9–12.) Plaintiff relies on this response to

demonstrate that time sheets were the only justification for plaintiff’s termination, but when

placed in proper context, the cited testimony does not support plaintiff’s position. Specifically,

plaintiff omits important preceding lines that show Cahill and her questioner were discussing

only the text of plaintiff’s termination letter, not defendant’s reasons for termination more

generally. (Cahill Dep. [72-8] at 155:15–156:12.) Moreover, during the same deposition, Cahill

had already stated there were other reasons for plaintiff’s removal:

Q. Your testimony earlier today I recall is that this was the only reason he was
terminated and I wanted to ask you if, in fact, this is the only reason he was

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terminated? A. I don’t remember saying it was the only reason. I know that also
in consideration was the behavior of Dr. Lurie on previous occasions. Concerns
about him were mitigating factors.

(Def.’s Reply Ex. 4 [77-4] 151:3–12.) At the end of the day, Cahill’s testimony establishes that

disciplinary problems played a role in plaintiff’s dismissal.

4. Defendant’s alleged pecuniary interest in plaintiff’s termination does not
show discrimination

Plaintiff alleges that defendant stood to gain financially by firing plaintiff as an older

doctor. Plaintiff’s position here rests on three pieces of evidence. First, he alleges that defendant

had changed the rules for its pension program so that physicians hired after 2000 could not retire

with full benefits until age 65. 4

(See Pl.’s Opp’n [72] at 17.) Second, Cahill once remarked to

plaintiff that he was “making too much money.” Third, Dr. Aryavand, plaintiff’s alleged,

younger replacement, was paid less money than and would retire at a later age than plaintiff.

Altering the pension program is not indicative of discriminatory intent. To begin,

plaintiff was hired well before the new policy took effect, (see Pl.’s Verified Compl. [72-3] ¶

10), and therefore, he and other longtime employees could not have been dissuaded from

remaining with defendant by the change. However, even if the changes did not affect plaintiff,

he may still contend that they are indicative of a generalized hostility towards older employees

harbored by defendant. On the contrary, increasing the retirement age is suggestive of a desire to

retain older physicians past the age of sixty rather than to hurry them out the door. At the end of

4 In his brief, plaintiff describes the pension rules as having been changed so as to exclude physicians hired after
2000 from retiring with full benefits at 65. (See Pl.’s Opp’n [72] at 17.) This may misrepresent the development of
defendant’s pension policy. The record is ambiguous; it may be the case that pre-2001 hires gained the ability to
retire at 60 while hires after that date were to be kept ineligible for full retirement until 65. (See Def.’s Reply Ex. 1
[77-1] ¶ 4; Pl.’s Ex. 13 [72-15] at 72:20–73:7.) Nonetheless, defendant does not dispute plaintiff’s account, and
either version of events should yield the same outcome on the discrimination question. Allowing full retirement at
sixty would only make employment with defendant more attractive for people in defendant’s age group, hardly a
way to purge one’s payrolls of workers between the ages of 40 and 60.

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the day, the Court does not see how a reasonable jury could infer discrimination from changes in

the pension plan.

On one occasion, Cahill observed to plaintiff that he was “making too much money.”

(Lurie Dep. [68-4] at 188:8–10.) Plaintiff interprets her words as expressing a desire to

terminate an older, better remunerated employee. Yet what plaintiff omits to mention is that

Cahill made the comment while discussing plaintiff’s use of ghost clinics. (Id. at 188:14–17.)

When Cahill expressed her opinion about plaintiff’s earnings, the circumstances suggest she did

so in relation to the extra pay he was receiving for ghost clinics, not entitlements accrued as an

older physician. In proper perspective, there is nothing insidious about Cahill’s remark.

Nonetheless, plaintiff attempts to link Cahill’s comment to the fact that Dr. Aryavand, his

alleged replacement, was paid substantially less than plaintiff and would not have been eligible

for full retirement until age 65. The Court has already addressed the argument that Dr.

Aaryavand was plaintiff’s replacement in the negative.

5. Isolated, derogatory remarks about plaintiff’s age do not show
discrimination

Fifth and finally, plaintiff relies on comments made by one of defendant’s managers, Dr.

Beaverson, about his age. In the course of a meeting at her office, Dr. Beaverson told plaintiff

that he had “gotten so old.” (Lurie Dep. [68-4] at 59:6–8.) Plaintiff’s claims notwithstanding,

Dr. Beaverson’s comments are insufficient to infer discrimination in the decision to terminate

plaintiff. “[S]tray remarks, ‘even those made by a supervisor, are insufficient to create a triable

issue of discrimination where, as here, they are unrelated to an employment decision involving

the plaintiff.’” Talavera v. Fore, 648 F. Supp. 2d 118, 132 (D.D.C. 2009) (quoting Simms v.

U.S. Gov’t Printing Office, 87 F. Supp. 2d 7, 9 n.2 (D.D.C. 2000)). Dr. Beaverson’s statement

qualifies as a stray remark; after the meeting in question, she and plaintiff had no further contact.

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(Lurie Dep. [68-4] at 195:9–14.) More to the point, although Dr. Beaverson was in management,

she was not involved in the decision to terminate plaintiff. (See Beaverson Aff. [77-2] ¶¶ 3, 7;

Lurie Dep. [68-4] 202:19–203:2.) In sum, Dr. Beaverson’s statement is insufficient to generate a

jury worthy issue on discrimination.

Having separately considered each of plaintiff’s arguments, the Court has discovered

nothing from which a reasonable jury could infer that the reasons given for plaintiff’s discharge

were a pretext for unlawful employment discrimination. Given the absence of evidence that

defendant’s stated reasons were insincere or that age was a factor in, let alone a but-for cause of,

plaintiff’s termination, the Court will grant summary judgment in defendant’s favor on plaintiff’s

ADEA claim.

C. ERISA

The Employee Retirement Income Security Act (ERISA) forbids an employer from

discharging a participant in an employee benefit plan for the purpose of interfering with the

attainment of any right under the plan. 29 U.S.C. § 1140. In interpreting ERISA, the Circuit

Court has followed the familiar burden shifting approach employed in Title VII and ADEA

cases. See May v. Shuttle, Inc., 129 F.3d 165, 169–70 (D.C. Cir. 1997). Under that framework,

the plaintiff is required to first make out a prima facie case of prohibited employer conduct

before the burden shifts to the defendant to articulate a legitimate reason for its action. Id. at

169. The burden then swings back to the plaintiff to prove that the presented reasons are

pretextual. Id. at 170.

Though May was following the state of the art in employment discrimination

jurisprudence, subsequent developments have altered the way courts in this circuit treat ADEA

and Title VII claims. See James v. Int’l Painters and Allied Trades Indus. Pension Plan, No. 07-

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2107, 2010 WL 1741114, at *12 (D.D.C. April 30, 2010). Specifically, the Circuit Court

directed in Brady that courts considering motions for summary judgment focus on the pretext

question. See Brady, 520 F.3d at 494. Once the defendant has proffered non-discriminatory

reasons for its actions, the court need no longer concern itself with whether the plaintiff has

made out a prima facie case. Id.

So far, the Circuit Court has not extended the methodology in Brady to claims under

ERISA. See James, 2010 WL 1741114, at *12. However, a fellow court in this district has with

good reason opted to apply Brady to an ERISA claim. See id. Updating ERISA interpretation to

correspond with developments in the application of Title VII is consistent with the Circuit

Court’s approach of maintaining both areas of the law in parallel. See id. Thus, the Court’s task

is to determine whether the evidence is sufficient to allow a reasonable juror to find that

defendant’s reasons for terminating plaintiff are a pretext for depriving him of his pension

benefits.

Plaintiff’s evidence in support of his ERISA claim is sparse. Plaintiff relies in large part

on his verified complaint in order to make his argument. The relevant section states,

Upon information and belief, one of the determining factors causing his
[plaintiff’s] termination was Defendant Kaiser’s desire to deprive Plaintiff Dr.
Lurie of further participation in “Defendant Kaiser’s pension plan and to avoid the
adverse economic impact which Plainitff Dr. Lurie’s continuation in the plan
would cause. Such discrimination was for the purpose of interfering with Plaintiff
Dr. Lurie’s attainment of rights to which he was entitled under Defendant
Kaiser’s pension plan, contrary to the provisions of Section 510 of ERISA.

(Pl.’s Verified Compl. [72-3] ¶ 12.)

There is some question as to the evidentiary status of this statement. The Circuit Court

has established that a verified compliant may be treated as an affidavit for summary judgment

purposes. See Neal v. Kelly, 963 F.2d 453, 457 (D.C. Cir. 1997). Nevertheless, rule 56(e)

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dictates that an “opposing affidavit must be made on personal knowledge, set out facts that

would be admissible in evidence, and show that the affiant is competent to testify on the matters

stated.” FED. R. CIV. P. 56(e).

Although plaintiff’s verified complaint may be dealt with as an affidavit, the statement in

question violates rule 56(e) and cannot be accorded weight in deciding the present motion for

summary judgment. Though plaintiff claims that his declaration derives from “information and

belief,” he does not point to specific facts or observations which would support his contention or

explain the provenance of his knowledge. (Pl.’s Opp’n [72] at 18.) The court, therefore, will not

consider the above section of plaintiff’s verified complaint in evaluating the sufficiency of the

evidence. See Greene v. Dalton, 164 F.3d 671, 675 (D.C. Cir. 1999) (refusing to credit

conclusory portion of plaintiff’s affidavit that stated, without support, that she was more

qualified than other applicants).

Aside from his verified complaint, plaintiff points to a few stray points in the evidence to

support his claim. (See Pl.’s Opp’n [72] at 19–20.) First, he relies on Cahill’s comment to

plaintiff that he was “making too much money.” (Pl.’s Opp’n [72] at 19.) As previously

addressed, plaintiff takes Cahill’s statement out-of-context. Cahill made the comment in the

course of a meeting about plaintiff’s use of ghost clinics; her reference to “making too much

money” was in regard to the extra hours plaintiff was billing, not his pension rights as a longtime

employee. (See Lurie Dep. [68-4] at 188:8–17.)

Second, plaintiff claims that defendant stood to save substantial sums by terminating him

and replacing him with younger doctors, like his alleged replacement Dr. Aryavand, who would

receive less lucrative pension packages. (Id. at 19–20). Plaintiff claims that his expert, Dr.

Bozilleri, is ready to testify that he would have been entitled to more than $900,000 in pension

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benefits had he not been fired. (Id. at 20.) Plaintiff, though, does not cite to record evidence

which would confirm the content or availability of Dr. Borzilleri’s testimony. (See id.)

Conversely, the record does show that plaintiff was already vested in the pension plan at the time

of his termination. (See Lurie Dep. [68-4] at 205:18–21.) In fact, plaintiff reaped its benefits by

electing to accept a lump sum distribution of his pension entitlements shortly after his firing.

(Def.’s Reply Ex. 1 [77-1] at ¶ 6.)

Third, plaintiff directs the Court’s attention to the deposition testimony of defendant’s

Chairman of the Board, Dr. Michell. (See Pl.’s Opp’n [72] at 19.) Plaintiff reads Dr. Michell’s

testimony for the proposition that defendant “changed its pension plan so that new employees

would no longer be able to receive full benefits at age 60.” (Id.) The Court has already noted

that plaintiff may have misrepresented Dr. Michell’s testimony with respect to the historical

development of the pension plan. Still, for present purposes, the Court may accept plaintiff’s

characterization as true.

Even if one accepts that the pension plan was altered to prevent new employees from

retiring with full benefits at age 60 and that defendant reaped some pension savings by firing

plaintiff, a reasonable jury could not infer that defendant’s reasons for firing plaintiff were a

pretext for depriving him of his pension benefits. It cannot be the case that every time an

employer alters its pension program or choose to fire an employee, the possibility of savings will

render its motives sufficiently suspect to create a jury issue. See May, 129 F.3d at 171

(“Plaintiffs must show more than that Shuttle [their employer] furloughed plaintiffs to save

money”); Conkwright v. Westinghouse Elec. Corp., 933 F.2d 231, 239 (4th Cir. 1991)

(“[Plaintiff’s] suggestion that [defendant] acted illegally because it acted to save money proves

too much. Under that reasoning, any actions by an employer that result in savings would be

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suspect.”). Something more is needed to show an illicit motive for the decision to sack an

employee, but no such additional evidence was forthcoming in this case. Therefore, defendant’s

motion for summary judgment on plaintiff’s ERISA claim will be granted.

D. Choice of Law

Plaintiff also asserts a number of common law claims over which the Court has

jurisdiction based on diversity of citizenship. When hearing diversity cases, the Court applies

the law of the forum state, including its choice of law rules. See Klaxon Co. v. Stenton Elec.

Mfg. Co., 313 U.S. 487, 496 (1941). According to the choice of law doctrine of the District of

Columbia, the Court’s first task is to determine if there is a conflict between the laws of relevant

jurisdictions. Eli Lilly and Co. v. Home Ins. Co., 64 F.2d 876, 882 (D.C. Cir. 1985) (citing

Fowler v. A&A Co., 262 A.2d 344, 348 (D.C. 1970); Gaither v. Meyers, 404 F.2d 216, 222 (D.C.

Cir. 1968)). If no conflict exists, it is unnecessary for the Court to make an ultimate choice of

law determination. See id.

Plaintiff is of the opinion that either District of Columbia law or that of California should

apply to his common law claims. (See Pl.’s Opp’n [72] at 22.) California, though, is not a

serious candidate. 5

For his part, defendant believes that the law of Maryland ought to govern.

(See Def.’s Reply to Opp’n to Mot. for Summ. J. [77] at 10 n.8, 23.) That being said, the Court

believes that identical results will be reached on all claims regardless of whether District of

Columbia or Maryland law is applied. Hence, the Court finds it unnecessary to conduct a choice

5 The only link between the present litigation and California is the affiliation of defendant with The Permanente
Medical Group, a medical group headquartered in California. (See Pl.’s Ex. 17 [72-19] at 2.) Just a glance at the
District of Columbia choice of law standard is enough to belie the notion that California law ought to apply. See
Drs. Groover, 917 A.2d at 1117; Greycoat, 657 A.2d at 767–68. The key events underlying this litigation took
place either in the District of Columbia or Maryland. (See, e.g., Pl.’s Verified Compl. [72-3] ¶¶ 10, 15, 16, 19.)
Plaintiff is a resident of the District of Columbia, and defendant has its principal place of business in Maryland.
(Pl.’s Verified Compl. [72-3] ¶¶ 5, 6.) Plaintiff admits the irrelevance of California law insofar as the majority of
his analysis follows Maryland and District of Columbia law with only sporadic references to California law and
policy preferences. (See Pl.’s Opp’n [72] at 22, 28).

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of law analysis and instead will present both District of Columbia and Maryland law as it

analyzes each cause of action.

E. Wrongful Discharge

Plaintiff argues that “wrongful discharge is grounded in both tort and contract” and

therefore bases his claim on violations of both defendant’s internal policies, like the employee

manual, and public policy. Clarifying plaintiff’s position, defendant correctly recognizes that

plaintiff’s wrongful discharge claim actually constitutes two distinct causes of action. Where the

plaintiff is relying on defendant’s internal documents or employee manual, his claim is an

implied contract claim, and where the plaintiff relies on public policy, he is pursuing the tort of

wrongful discharge. Compare Fingerhut v. Children’s Nat’l Med. Ctr., 738 A.2d 799, 803 (D.C.

1999) (discussing the history of the intentional tort for wrongful discharge in violation of public

policy), and Wholey v. Sears Roebuck, 803 A.2d 482, 488 (Md. 2002) (recognizing wrongful

discharge as a tort based on violation of public policy), with Strass v. Kaiser Found. Health Plan

of Mid-Atlantic, 744 A.2d 1000, 1011 (D.C. 2000) (“The terms of an employer’s personnel or

policy manual may be sufficient to raise a jury question as to whether the manual creates

contractual rights for the employee.”), and Dahl v. Brunswick Corp., 356 A.2d 221, 224 (Md.

1976) (allowing that an “employer’s policy directives regarding aspects of the employment

relationship” may develop into contractual obligations).

1. Implied Contract

The District of Columbia and Maryland follow the common law rule that generally an

employment relationship is terminable at will. Strass, 744 A.2d at 1011 (quoting Nickens v.

Labor Agency of Metropolitan Washington, 600 A.2d 813, 816 (D.C. 1991)); Caldor Inc. v.

Bowden, 625 A.2d 959, 965 (Md. 1993). Both jurisdictions recognize that an employer’s

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internal policies and employment literature may, in certain circumstances, give rise to a

contractual right to employment. Strass, 744 A.2d at 1011; Dahl, 356 A.2d at 224. However,

where the internal materials relied upon expressly disclaim contractual intent, “employees may

not rely on other statements in the handbook to argue that a contract has been formed.” Hyman

v. First Union Corp., 982 F. Supp. 8, 12 (D.D.C. 1997) (citing Castiglione v. Johns Hopkins

Hosp., 517 A.2d 786, 794 (Md. Ct. Spec. App. 1986). In the District of Columbia, the materials

also “must contain language clearly reserving the employer’s right to terminate at will” in order

to foreclose the possibility of a contractual interpretation. Boulton v. Inst. of Int’l Educ., 808

A.2d 499, 505 (D.C. 2002) (quoting Sisco v. GSA Nat’l Capital Fed. Credit Union, 689 A.2d 52,

55 (D.C. 1997)).

Although plaintiff comes before the Court with a heap of defendant’s internal papers, the

policy documents on which he relies either contain effective disclaimers or are irrelevant to his

employment status. Examples of irrelevant policies include defendant’s reporting requirements

for physicians, Kaiser Permanente’s National Patient Safety Program, defendant’s Electronic

Asset Usage Policy, and defendant’s Research and Publications Policy. (See Pl.’s Opp’n [72] at

26–27, 34–35.) Other documents which could be construed to alter plaintiff’s employment status

from that of an at-will employee emphatically disclaim contractual intent and alteration of the at-

will relationship. (See Pl.’s Ex. 19 [72-21] at 3,12, 25, 43). For instance, though the Progressive

Discipline Policy outlines steps to be taken before terminating an employee, it also includes

unequivocal terms disclaiming contractual intent and alteration of employees’ at-will status. (Id.

at 3–6.) Since plaintiff is unable to point the Court to any internal policy, not properly

disclaimed, that would alter the default at-will employment relationship, the Court will grant

summary judgment in favor of defendant on plaintiff’s implied contract claim.

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2. Public Policy Wrongful Discharge

An employee may bring suit against an employer for wrongful termination in violation of

public policy. See Wholey, 803 A.2d at 488; Fingerhut, 738 A.2d at 803. In Maryland, “the

basis for the employee’s discharge must violate some clear mandate of public policy, and there

must be a nexus between the employee’s conduct and the employer’s decision to fire the

employee.” Wholey, 803 A.2d at 489. While it admitted to making exceptions, the Maryland

Court of Appeals strongly cautioned against applying broad notions of public policy that step

outside the boundaries of pre-existing law. See id. at 490–91. The court stated, “[a] limiting

factor in defining a public policy mandate as a cause of action in tort is the notion that the

policies should be reasonably discernible from prescribed constitutional or statutory mandates.”

Id.

Adopting similar standards, a majority of the District of Columbia Court of Appeals held

that “there must be a close fit between the policy thus declared and the conduct at issue in the

allegedly wrongful termination” which policy must be “firmly anchored either in the

Constitution or in a statute or regulation which clearly reflects the particular ‘public policy’

being relied upon.” See Fingerhut, 738 A.2d at 803 n.7 (quoting Carl v. Children’s Hosp., 702

A.2d 159, 162, 164 (D.C. 1997) (Terry, J., concurring)).

Plaintiff’s public policy arguments center on the claim that his termination was driven by

hostility against his unwelcome attempts at exposing and reforming bad medical practices. (See

Pl.’s Opp’n [72] at 36.) Even if one accepts plaintiff’s account of himself as a whistleblower

punished for his good deeds, plaintiff is unable to identify an appropriate public policy on which

to base his claim.

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Some of the policy grounds that plaintiff advances are less appropriate than others. (See

Pl.’s Opp’n [72] at 27–29, 32.) For example, plaintiff references the professional standards of

the American Medical Association and the Medical and Chirurgical Faculty of Maryland. (See

Pl.’s Opp’n [72] at 27–28, 32.) Given that Maryland and District of Columbia courts have either

strongly cautioned against or forbidden the use of extralegal materials in formulating public

policy exceptions to the at-will employment doctrine, the Court will not consider the professional

standards cited by plaintiff but instead will confine itself to an examination of plaintiff’s

governmental policy sources. See Wholey, 803 A.2d at 490–91; Fingerhut, 738 A.2d at 803 n.7.

Plaintiff looks for applicable public policy in a District of Columbia statute, D.C. CODE §

7-161 (2010), requiring that health care providers submit reports of adverse medical events to

local government. (See Pl.’s Opp’n [72] at 28.) Plaintiff’s reliance is misplaced however.

Significantly, plaintiff does not allege that he was terminated for attempting to submit the

required reports or otherwise take his grievances about patient care to government authorities.

Thus, the Court is unable to find the requisite close fit between plaintiff’s conduct and a statute

clearly expressing favorable public policy.

Plaintiff also seeks support from a Maryland statute, MD. CODE ANN., HEALTH OCC. §

14-502 (West 2010), giving physicians protection from civil liability for reporting information

about other physicians to various health care institutions such as hospitals and licensing boards

“with the intention of aiding in the evaluation of the qualifications, fitness, or character of a

physician.” MD. CODE ANN., CTS. & JUD. PROC. § 5-638; (See Pl.’s Opp’n [72] at 28, 29–30.)

According to plaintiff, “such immunities are granted to physicians to provide incentive for

physicians and others to participate in medical peer review and other processes to insure quality

medical care.” (Pl.’s Opp’n [72] at 29–30.) The relationship, however, between the statute in

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question and plaintiff’s behavior is too attenuated to meet the stringent standard for recognizing

public policy exceptions to the at-will employment doctrine. In particular, the statute makes no

mention of a physician’s employment status or job security but instead only assures protection

from litigation. See MD. CODE ANN., HEALTH OCC. § 14-502; cf. Makovi v. Sherwin Williams

Co., 561 A.2d 179, 190 (Md. 1988) (holding that plaintiff could not rely on sex discrimination

statute to establish a wrongful discharge claim as statute provided its own civil remedy). It also

is not specifically addressed to countering medical negligence but rather is explicitly directed to

aiding evaluation of physicians’ qualifications. See MD. CODE ANN., HEALTH OCC. § 14-502

(extending MD. CODE ANN., CTS. & JUD. PROC. § 5-638). Ultimately, the statute does not present

a clear mandate of public policy of the kind which the Maryland Court of Appeals cautiously

allowed could form the basis of a wrongful discharge claim. See Wholey, 803 A.2d at 490–91.

Plaintiff claims that “[f]ederal law encourages physicians to report quality of care issues

and grants physicians immunity for reporting quality of care issues.” (Pl.’s Opp’n [72] at 28

(citing Health Care Quality Improvement Act of 1986 (HCQIA), 42 U.S.C. § 11101, 11111–

11115, 11131–37, 11151–52.) However, the statute deals only with narrowly defined

professional review actions by professional review bodies, granting civil immunity to the

committees themselves and testifying physicians. See id. Plaintiff does not allege that he

participated on or gave testimony to such a committee. HCQIA is inappropriate as a policy basis

for plaintiff’s claim.

Plaintiff also cites a federal regulation, 45 C.F.R. pt. 88 (2010), which he interprets as

“protect[ing] physicians from being fired, disciplined or penalized . . . for refusing to participate

in any care they consider objectionable on ethical, moral or religious grounds.” (Pl.’s Opp’n [72]

at 28.) The rule is inapposite for several reasons. First, its express purpose is to implement

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various statutes which bar recipients of Federal healthcare dollars from prejudicing physicians

who refuse on ethical or religious grounds to perform medical procedures or research. See 45

C.F.R. § 88.1. Plaintiff has not alleged that defendant is a recipient of such funds. Moreover,

the regulation is plainly limited to denying Federal financing to organizations that discriminate

on grounds of conscience, not to forbidding the discharge of scrupulous physicians in general.

See id. Second, though plaintiff objected to working with incompetent or dangerous residents

and felt a clash of values with WHC, one would be hard pressed to identify the specific moral

convictions underlying plaintiff’s objections. (See Lurie Dep. [68-4] at 108:3–6, 115:16–

116:21.)

Finally, plaintiff invokes another District of Columbia statute, D.C. Code § 44-507,

which prescribes procedures for evaluating the qualifications of health care professionals for

staff positions and clinical privileges. (See Pl.’s Opp’n [72] at 28.) Plaintiff is far off the mark

in presenting the statute as a basis for his wrongful termination claim. The law in question does

not apply to private medical groups like defendant. See D.C. Code § 44-501.

E. The Graftcath Contract (Breach of Contract and Implied Contract)

Plaintiff asserts two claims based on the Graftcath contract (Contract). First, plaintiff

claims that defendant breached the Contract by firing him, making it impossible for him to

perform the Contract.. (See Pl.’s Opp’n [72] at 36–37.) Second, plaintiff asserts that the

Contract created an implied employment agreement which defendant breached when it

terminated plaintiff. (See id. at 38.) In both cases, the defendant is alleged to have breached the

Contract by discharging plaintiff. The resolution of both claims thus turns on the question of

whether the Contract limited defendant’s right to terminate plaintiff.

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Where employer and employee have not agreed upon a period of employment, the

District of Columbia and Maryland largely follow the common law rule that the employment

relationship is terminable at will. See Strass, 744 A.2d at 1011; Adler v. Am. Standard Corp.,

432 A.2d 464, 467 (Md. 1981). In this case, the alleged employment contract was memorialized

in writing. “As a general rule, the construction or interpretation of all written instruments is a

question of law for the court is a principle of law that does not admit of doubt.” Gordy v. Ocean

Park Inc., 145 A.2d 273, 277 (Md. 1958); accord 1010 Potomac Assocs. v. Grocery Mfrs. of Am.

Inc., 485 A.2d 199, 205 (D.C. 1984) (“[T]he interpretation of an integrated contract is a question

of law . . .”). For District of Columbia employment agreements, “[i]t has been required . . . that

the parties clearly state their intention to alter an at-will employment agreement in order to make

such an alteration effective.” Rinck v. Ass’n of Reserve City Bankers, 676 A.2d 12, 16 (D.C.

1996) (citing Littell v. Evening Star Newspaper Co., 120 F.2d 36, 37 (D.C. Cir. 1941)).

Nevertheless, “[w]here the intent is not clearly revealed by the express terms of the agreement,

the courts will look to evidence of surrounding circumstances to determine what was in the

minds of the contracting parties.” Littell, 120 F.2d at 37.

Although aspects of the Contract support plaintiff’s interpretation, the Court does not

believe that the document can be fairly interpreted to alter the employment relationship between

plaintiff and defendant. It is true that as Principal Investigator plaintiff possessed a host of

responsibilities for overseeing the clinical trial of the Graftcath device. (See, e.g., Def.’s Ex. 18

at 2.) Equally true, the Contract states, “The Institution [defendant] will conduct the Clinical

Trial during the period beginning May 2005, and ending May 2007.” (Id. at 1). Given his duties

on what was to be a multiyear project, plaintiff declares that he was “entitled to an expectation of

working for two years.” (Pl.’s Opp’n [72] at 39). Nevertheless, nothing in the Contract,

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expressly or otherwise, speaks of plaintiff embarking on a course of employment with defendant.

In fact, certain language militates against that interpretation. Under the “Background” heading,

the Contract states, “The Institution [defendant] employs the Principal Investigator, Kevin Lurie,

MD.” (Def.’s Ex. 18 at 1). The use of the present tense apparently refers to plaintiff’s status as a

preexisting employee.

Similarly, under District of Columbia law, the evidence is inadequate to show alteration

of the at-will employment relationship. The parties did not clearly state their intention to change

plaintiff’s employment status. Additionally, plaintiff points to little evidence of surrounding

circumstances which would allow the Court to infer that it was the parties’ intent to guarantee

him employment until the end of the project. (See Pl.’s Opp’n [72] at 38). Prior to signing the

Contract, plaintiff did play a major role in procuring the clinical trial. (See Pl.’s Statement [72-1]

¶ 185; Pl.’s Ex. 10 [72-12] at 240:2–12.) Plaintiff may have felt entitled to remain involved in

the clinical trial given his role in procuring it, but since plaintiff had already performed this

service, there could have been no quid-pro-quo at the time the parties signed the Contract. Cf.

Riefkin v. E.I. Du Pont De Nemours & Co., 290 F. 286, 289 (D.C. Cir. 1923) (finding that where

contract spoke of permanent employment and plaintiff had given additional consideration by

promising to quit his former job, the parties could not have contemplated at-will employment).

The Maryland reporters contain an employment case similar to that before the Court but

with important differences that mark out the limits of Maryland doctrine on when an agreement

creates a right to employment for a defined period. Sperling v. Terry, 135 A.2d 309 (Md. 1957).

In Sperling, the Maryland Court of Appeals found that a contract to supervise the construction of

a house created an implied right of employment until the completion of the house. Id. at 311.

The Graftcath contract is significantly different in that it did not originate the employment

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relationship or limit that relationship to completion of a single task. See Lubore v. RPM Assocs.,

674 A.2d 547, 554 (Md. Ct. Spec. App. 1996) (distinguishing Sperling where “the period of

appellant’s employment was not tied to the accomplishment of any particularly defined task, the

duration of which is fixed or finite”). 6

Standing alone, plaintiff’s expectation that he would

continue to be a part of the research project is not enough to prove alteration of the at-will

employment relationship. Cf. Lubore, 674 A.2d at 554 (finding that plaintiff’s employment was

at-will despite the fact that plaintiff’s contract contained salary projections for the next two years

and described job responsibilities involving long term planning).

Whether under Maryland or District of Columbia law, defendant retained the right to

terminate plaintiff and did not breach the Contract when it did so. Summary judgment will be

granted in favor of the defendant on plaintiff’s claims arising under the Contract.

F. Tortious Interference

Plaintiff alleges that defendant has tortiously interfered with his new and independent

surgical practice. (See Pl.’s Opp’n [72] at 39.) The elements of tortious interference with

contractual or business relations are well established. In Maryland, the tort requires: “(1)

intentional and willful acts; (2) calculated to cause damage to the plaintiffs in their lawful

business; (3) done with the unlawful purpose to cause such damage and loss, without right or

justifiable cause on the part of the defendants (which constitutes malice); and (4) actual damage

and loss resulting.” Kaser v. Fin. Prot. Mktg., Inc., 831 A.2d 49, 54 (Md. 2003) (quoting Willner

v. Silverman, 71 A. 962, 964 (Md. 1909)). In the District of Columbia, one must prove: “(1)

6 The interpretation put on Sperling by the Maryland Court of Special Appeals (the intermediate court) is well-
founded. In the Sperling opinion, the Maryland Court of Appeals (the high court) emphasized the contract’s one-off
character: “It will be noted that the appellant was not in the building business. He was going to erect a single
dwelling, for use as his abode. This, ordinarily, would require between two and four months. For him, it was an
isolated undertaking. He needed a supervisor, so he employed the appellee to ‘supervise and work on the
construction of a private dwelling’, ‘all labor and materials to be furnished by’ the appellant.” Sperling, 135 A.2d at
311 (emphasis added).

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existence of a valid contractual or other business relationship; (2) the defendant’s knowledge of

the relationship; (3) intentional interference with that relationship by the defendant; and (4)

resulting damages.” NCRIC, Inc. v. Columbia Hosp. for Women Med. Ctr., 957 A.2d 890, 900

(D.C. 2008) (footnote omitted).

1. Defendant did not tortiously interfere with plaintiff’s practice by
misleading former patients

Plaintiff first argues that defendant discouraged patients from seeing him and misled

them about whether their insurance covered treatment by plaintiff. (See Pl.’s Opp’n [72] at 40.)

Plaintiff points to the experience of Geraldine Edwards and Judy Gantt. (See id.) Plaintiff

claims that he had an existing business relationship or expectancy with both women, likely

referring to care he provided for them while still employed with defendant (See id. at 41; Gantt

Dep. [72-10] at 27:14–28:9.)

Significantly, plaintiff does not allege that he had a relationship with Gantt or Edwards

outside that developed whilst treating them as an employee of defendant. (See Pl.’s Opp’n [72]

at 4041.). Thus, to the extent that they were plaintiff’s clients, they were also defendant’s

clients, a dispositive fact under Maryland law. Since defendant lacked an independent economic

relationship with these potential clients, the defendant could not have tortiously interfered with

that relationship. See Kaser, 831 A.2d at 59 (finding against insurance subagent who alleged

tortious interference against general agent but lacked an economic relationship with the client

that was separate and independent).

Plaintiff’s evidence is likewise inadequate per District of Columbia standards. Namely,

plaintiff fails to make an adequate showing on the elements of intent and damages. “To establish

a prima facie case of interference with business relations, ‘a plaintiff must show that the

interference was intentional and that there was resulting damage.’” Brown v. Carr, 503 A.2d

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1241, 1247 (D.C. 1986) (quoting Alfred A. Altimont, Inc. v. Chatelain, Samperton & Nolan, 374

A.2d 284, 289 (D.C. 1977)).

If defendant’s doctors intentionally misled Gantt and Edwards about their insurance

coverage, one could infer intent to interfere with plaintiff’s business. However, the evidence that

defendants deceived the two patients is vague and equivocal; both women’s affidavits merely

state, “Drs. Lustgarten and Aryavand discouraged me from seeing Dr. Lurie and told me that my

insurance would not cover my care.” (Pl.’s Ex. 3 [72-5] ¶ 5; Pl.’s Ex. 4 [72-6] ¶ 5.) Plaintiff’s

reliance on the affidavits is undercut by the clarifying deposition testimony of Gantt. When

asked about her conversations with Drs. Lustgarten and Aryavand, Gantt claims they told her she

could not use plaintiff for her surgery. (See Gantt Dep. [72-10] at 914). She goes on to clarify

though that the doctors were speaking about Kaiser’s coverage for procedures performed by

plaintiff. (See id. at 25:15–26:5.) Gantt explains that she chose to use Kaiser initially but then

later opted to use Medicare and be treated by plaintiff. (See id. at 26:9–22.) While evidence of

deceit could serve as circumstantial evidence of intent to interfere, Gantt’s deposition testimony

seems to show Drs. Lustgarten and Aryavand explaining the status of Gantt’s coverage with

Kaiser. It would be a stretch to say they categorically claimed Gantt lacked insurance which

would allow her to see plaintiff if she so desired.

Gantt’s testimony indicates plaintiff did not suffer damages. As Gantt explained, she was

always aware that treatment by plaintiff was an option and that Medicare would pay for that

treatment. (See id. at 26:3–8.) Though she originally chose to receive treatment from Kaiser

practitioners, she ultimately turned to plaintiff for her surgical needs. (See id. at 26:1222.)

Supporting that testimony, plaintiff admits that he eventually operated successfully on both

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women. (See Pl.’s Opp’n [72] at 40.) If Gantt was unaffected by any misinformation on the part

of defendant’s employees, defendant did not cause plaintiff to lose her business.

2. Defendant’s decision to refuse plaintiff admission to its referring provider
network was not tortious interference

Plaintiff tries to ground his interference claim on defendant’s decision to refuse him entry

into the Kaiser referring provider network. (See id. at 42). Supporting his position, he writes,

“Plaintiff had a 17-year relationship with Defendant. He had relationships with the physicians

with whom he worked and with the patients he treated.” (Id.) There are several problems with

plaintiff’s argument. To begin, plaintiff does not point the Court to examples of harm to his

surgical practice produced by the ongoing fissure in the relationships he identifies. The Court is

thus unable to identify any evidence of damages suffered by plaintiff.

Further, the Court cannot discern with sufficient specificity the economic relationships or

business expectancies that were allegedly compromised by defendant’s actions. Blanket

accusations do not point the Court to the existence of particular “business expectancies” that are

“commercially reasonable to anticipate.” Carr v. Brown, 395 A.2d 79, 84 (D.C. 1978)

(describing those relationships that are protected from unjustified interference).

Plaintiff’s allegations of broken connections with coworkers and patients are particularly

deficient under Maryland law. To wit, the relationships with coworkers and patients that

plaintiff formed while employed with defendant are not independent economic relationships with

which defendant might interfere. See Kaser, 831 A.2d at 59.

3. If plaintiff was not paid for treating Kaiser patients, his grievance is not
with defendant, and his remedy is in contract, not tort.

Plaintiff claims that he has not received payment for seeing patients referred to him by

defendant’s physicians. (See Pl.’s Opp’n [72] at 41.) Even if true, this allegation is irrelevant for

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two reasons. First, if plaintiff has not been paid for services rendered to patients covered by

Kaiser Health Plan insurance, then his grievance is with the Kaiser Health Plan, not with

defendant MAPMG. (See Lurie Dep. [68-4] at 340:20–342:3.) Second, if defendant or Kaiser

Health Insurance has wrongly refused to honor plaintiff’s bills, his remedy is in contract, not in

tort. Courts have steadfastly resisted efforts to convert an action for breach of contract into a suit

for tortious interference. See Alexander & Alexander, Inc. v. B. Dixon Evander & Assocs., 650

A.2d 260, 269–270 (Md. 1994); Raskauskas, 589 A.2d at 26 (explicating “the common sense

notion that a plaintiff should not be allowed to convert a breach of contract claim into a claim for

tortious interference”).

V. Defendant’s Counterclaims

Defendant asserts causes of action for breach of contract, fraud, negligent

misrepresentation, and unjust enrichment. It claims the Court may consider its counterclaim

pursuant to both its diversity, 28 U.S.C. § 1332, and supplemental jurisdiction, 28 U.S.C. § 1367.

(See Countercl. [2] at 1.)

A. Diversity of Citizenship

The Constitution and statutes limit the subject matter jurisdiction of the Federal Court.

See Kokkonen v. Guardian Life Insurance Co. of America, 511 U.S. 375, 377 (1994). The

Federal Courts have diversity jurisdiction over civil actions between citizens of different states

where the amount in controversy is greater than $75,000, exclusive of interests and costs. See 28

U.S.C. § 1332. In calculating the amount in controversy, “the sum claimed by the plaintiff

controls if the claim is apparently made in good faith.” St. Paul Mercury Indem. Co. v. Red Cab

Co., 303 U.S. 283, 288 (1938) (footnote omitted). Further, “it must appear to a legal certainty

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that the claim is really for less than the jurisdictional amount to justify dismissal.” St. Paul, 303

U.S. at 289.

When appraising the amount in controversy, courts are not confined to examining the

amount of actual damages. For instance, courts should include the value of any injunctive or

declarative relief sought. See Hunt v. Wash. State Apple Adver. Comm’n, 432 U.S. 333, 347

(1977). “In actions seeking declaratory or injunctive relief, it is well established that the amount

in controversy is measured by the value of the object of the litigation.” Hunt, 432 U.S. at 347.

Further, the value may be measured from either the perspective of the plaintiff or the defendant.

See Comm. for GI Rights v. Calloway, 518 F.2d 466, 472 (D.C. Cir. 1975) (quoting Tatum v.

Laird, 444 F.2d 947, 951 (D.C. Cir. 1971), rev’d on other grounds, 408 U.S. 1 (1972)).

Requests for punitive damages should likewise be considered, Bell v. Preferred Life

Assurance Soc’y of Montgomery, Ala., 320 U.S. 238, 240 (1943), albeit with a skeptical eye. “In

applying the legal certainty test where the availability of punitive damages is the sine qua non

[essential element] of federal jurisdiction the District Court should scrutinize the punitive

damage claim to ensure that it has at least a colorable basis in law and fact.” Kahn v. J. W.

Wilson & Assocs, 673 F.2d 547, 549 (D.C. Cir. 1982) (citing Zahn v. International Paper Co.,

469 F.2d 1033, 1034 n.1 (2d Cir. 1972), aff’d, 414 U.S. 291 (1973); Nelson v. Keefer, 451 F.2d

289, 293–98 (3d Cir. 1971). “Liberal pleading rules are not a license for plaintiffs to shoehorn

essentially local actions into federal court through extravagant or invalid punitive damage

claims.” Id. at 549.

To evaluate punitive damages requests, “[f]irst, the court must determine whether the plaintiff

can recover punitive damages as a matter of governing substantive law. Nwachukwu v. Carl, 223

F.Supp. 2d 60, 66 (D.D.C. 2002) (citing Bell v. Preferred Life Assurance Soc’y of Montgomery,

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Ala., 320 U.S. 238, 240 (1943)). If the plaintiff can recover as a matter of law, “the court has

subject matter jurisdiction unless it is clear beyond a legal certainty that the plaintiff would under

no circumstances be entitled to recover the jurisdictional amount.” Id. (citing Cadek v. Great

Lakes Dragaway, Inc., 58 F.3d 1209, 1212 (7th Cir.1995)). In this second step, the plaintiff must

present factual evidence of entitlement to punitive damages. Id. (citing Larkin v. Brown, 41 F.3d

387, 388–89 (8th Cir.1994)); see also McQueen v. Woodstream Corp., 672 F. Supp. 2d 84, 88

(D.D.C. 2009).

In contrast to the acceptance of punitive damages, courts in this circuit have refused to

take into account attorney’s fees when deciding whether a litigant has met the jurisdictional

minimum, albeit with an exception for fees provided for by statute or contract. See G. Keys

PC/Logis NP v. Pope, 630 F.Supp. 2d 13, 17 (D.D.C. 2009) (citing a number of examples).

In the instant case, although the defendant invokes the Court’s diversity jurisdiction, it

does not request a specific amount of damages or give an estimate of the amount of damages it

hopes to recover. (See Countercl. [2] at 1, 4.) Instead, at the bottom of its complaint, defendant

requests, “1. Consequential and punitive damages in an amount to be proven at trial; 2. An

accounting for all compensation received by Lurie based on falsified records and information

submitted to MAPMG; 3. The costs incurred by MAPMG in prosecuting this Counterclaim; and

4. Such other relief deemed appropriate by the Court.” (Id. at 4.) As a result, the Court must

look to the body of the complaint to ascertain the basis for the anticipated damages.

1. Defendant’s actual damages are far less than $75,000

With respect to actual damages, defendant seeks the same recovery for each of cause of

action. (See id. at 2–4.) For the breach of contract, fraud, and negligent misrepresentation

claims, defendant declares that it has sustained damages in the amount of compensation that was

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paid to plaintiff for ghost clinics. (See id.) Similarly, defendant’s unjust enrichment claim is

presumably based on the monies retained by plaintiff that he derived from ghost clinics. (See id.

at 4.) Defendant’s alleged actual damages in this case are therefore equivalent to the payments

plaintiff received from operating ghost clinics.

To determine the magnitude of the ghost clinic payments defendant could prove at trial,

the Court looks to the record. The affidavit of Ann Cahill furnishes the most obvious guidepost;

she avers, “Dr. Lurie had obtained at least $8,344.96 in extra pay by submitting falsified time

sheets which showed that he had worked the ghost clinics.” (See Cahill Aff. [71-2] ¶ 7

(emphasis added.)) Assessing Cahill’s statement, the Court is aware that Cahill is literally

stating a minimum figure. Still, $8,344.96 is a reasonable estimate in light of the number of

ghost clinic hours that plaintiff claimed.

Looking at the alleged offending time sheets,

defendant added fifty-six hours to his timesheets for ghost clinics. (See Dr. Lurie’s Timesheets

Re: Ghost Clinics [71-6].) Though the Court has not located information in the record that

would allow it to determine the pay rate for the hours, useful assessments can be made from this

information nonetheless. If one divides the sum given by Cahill by fifty-six, one finds a

plausible hourly rate of $149.02. In contrast, plaintiff would have had to receive $1,339.29 for

each ghost clinic hour in order to reach the jurisdictional minimum of $75,000. 7

The number

referenced by Cahill, $8,344.96, appears then to be a reasonable estimate of the amount of actual

damages which defendant could prove at trial. A substantially greater estimate, one approaching

$75,000 for instance, would be unfounded.

7 For comparison, by the time he was fired in October of 2005, Dr. Lurie’s W2 wages for that year stood at
$317,424.17. (See Cahill Aff. [68-1] ¶ 19.) If he were generally being compensated at a rate of $1,339.29 per hour,
he would have only had to work approximately 237 hours to earn that sum, just roughly six forty hour weeks.

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2. Defendant is not entitled to punitive damages

Given special circumstances, both the District of Columbia and Maryland allow a litigant

to recover punitive damages. “Maryland law has limited the availability of punitive damages to

situations in which the defendant’s conduct is characterized by knowing and deliberate

wrongdoing.” Ellerin v. Fairfax Sav., F.S.B., 652 A.2d 1117, 1123 (Md. 1995). In the District

of Columbia, “Punitive damages may be awarded ‘only if it is shown by clear and convincing

evidence that the tort committed by the defendant was aggravated by egregious conduct and a

state of mind that justifies punitive damages.’” Chatman v. Lawlor, 831 A.2d 395, 400 (D.C.

2003) (quoting Jonathan Woodner Co. v. Breeden, 665 A.2d 929, 938 (D.C. 1995)). The state of

mind required is similar to that in Maryland, “outrageous conduct which is malicious, wanton,

reckless, or in willful disregard for another’s rights.” Id. (quoting Vassiliades v. Garfinckel’s,

Brooks Brothers, Miller & Rhoades, Inc., 492 A.2d 580, 593 (D.C. 1985)). In either jurisdiction,

the requisite bad conduct for an award of punitive damages must be proven by clear and

convincing evidence. See Chatman, 831 A.2d at 400; Owens-Illinois, Inc. v. Zenobia, 601 A.2d

633, 657 (Md. 1992). Further, neither jurisdiction will allow punitive damages to be imposed for

a pure breach of contract. See Bowden v. Caldor, Inc., 710 A.2d 267, 276 (Md. 1998); Choharis

v. State Farm Fire and Cas. Co., 961 A.2d 1080, 1090 (D.C. 2008) (quoting Sere v. Group

Hospitalization, Inc., 443 A.2d 33, 37 (D.C. 1982)).

Though defendant requests punitive damages in its complaint, it does not explain the

basis for that request. (See Countercl. [2] at 4.) In particular, it fails to identify the specific

claims for which it believes imposition of punitive damages is appropriate. However, defendant

does allege facts in connection with its fraud claim which if properly proven would entitle it to

recover punitive damages. (See id. at 3.) It writes, “Lurie acted willfully, maliciously,

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intentionally, knowingly, and in wanton disregard of MAPMG’s rights and interests by

submitting the falsified reports and information.” (Id.)

Defendant fails to substantiate its allegation with argument or evidence. In its brief,

defendant broadly claims that plaintiff engaged in “conduct which a jury could reasonably find

Dr. Lurie had pursued to circumvent MAPMG’s practice of not paying surgeons additional

compensation based on the number of patients seen during the normal work day.” (Def.’s Opp’n

[71] at 20.) Defendant’s representations notwithstanding, the Court cannot locate adequate

evidence speaking to plaintiff’s mental state. Since plaintiff is without a basis for justifying his

punitive damage request, the Court will not consider defendant’s request for punitive damages in

determining the amount in controversy. In making its decision, the Court is mindful of the

admonition of the Court of Appeals to carefully examine clams for punitive damages so as to

prevent unsubstantiated requests for punitive damages from becoming a password into the

Federal courts. See Kahal, 673 F.2d at 549.

3. The value of the declarative relief sought by plaintiff is negligible

Regardless of which method is used to quantify its value, the Court cannot imagine

attaching a high price tag to the accounting requested by defendant. Defendant assumedly

possesses all of the relevant documents; it produced plaintiff’s allegedly fraudulent timesheets in

discovery. (Lurie’s Timesheets [71-6].) Since the timesheets number just twenty-nine pages, the

Court was able to count the allegedly fraudulent hours in a matter of minutes with nothing more

than a pen and paper tally. One assumes that defendant could take the same steps then multiply

the number of hours by the rate it paid plaintiff and do it all for less than $10,000. At the end of

the day, the Court has no reason to assign a substantial value to the accounting sought by

defendant.

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Of the possible bases for relief considered, only plaintiff’s request for consequential

damages involves a substantial sum. Nonetheless, the allegedly undeserved payments to plaintiff

plainly do not amount to more than the statutory minimum. Accordingly, the Court finds that it

“appear[s] to a legal certainty that the claim is really for less than the jurisdictional amount.” St.

Paul, 303 U.S. 283 at 289. As a result, the Court lacks jurisdiction pursuant to § 1332.

B. Supplemental Jurisdiction

“[I]n any civil action of which the district courts have original jurisdiction, the district

courts shall have supplemental jurisdiction over all other claims that are so related to claims in

the action within such original jurisdiction that they form part of the same case or controversy

under Article III of the United States Constitution.” 28 U.S.C. § 1367. However, district courts

have discretion to refuse to exercise supplemental jurisdiction in certain circumstances, including

when “the district court has dismissed all claims over which it has original jurisdiction.” Id.

The Court has determined that summary judgment is proper with respect to the claims in

plaintiff’s complaint over which it has original jurisdiction. All of the causes of action described

in defendant’s counterclaim are founded in state law and have been found to lack an independent

basis in the Court’s diversity jurisdiction. The Court can and will exercise its discretion to

dismiss them.8

See Shekoyan v. Sibley Int’l, 409 F.3d 414, 423 (D.C. Cir. 2005) (“Whether to

retain jurisdiction over pendent state and common law claims after the dismissal of the federal

claims is ‘a matter left to the sound discretion of the district court’ that we review for abuse of

discretion only.” (quoting Edmondson & Gallagher v. Alban Towers Tenants Ass’n, 48 F.3d

1260, 1265-66 (D.C. Cir.1995)).

8 Since the Court would exercise its discretion to dismiss the claims given either outcome, the Court need not decide
whether the counterclaim forms part of the same case or controversy as the claims in the original complaint over
which it has original jurisdiction.

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V.

Conclusion

Despite its faults, plaintiff’s statement of material fact is not so improper as to justify

striking it. Accordingly, defendant’s motion [78] to strike will be DENIED. Since plaintiff fails

to present sufficient evidence from which a reasonable jury could find in his favor, the Court will

GRANT defendant’s motion [68] for summary judgment. Finally, the Court finds diversity

jurisdiction lacking over defendant’s counterclaims and declines to exercise supplementary

jurisdiction. Therefore, the Court will DISMISS defendant’s counterclaims and does not reach

plaintiff’s motion [69] for summary judgment.

A separate order shall issue this date.

August 9, 2010

_____/s/_________
ROYCE C. LAMBERTH
Chief Judge
United States District Court

41

Lyons v. Iowa Bd. of Med. (Summary)

Lyons v. Iowa Bd. of Med. (Summary)

PHYSICIAN LICENSURE

Lyons v. Iowa Bd. of Med., No. 08-1538 (Iowa Ct. App. June 17, 2009)

The Iowa Court of Appeals affirmed a lower court’s decision, upholding the Iowa Board of Medicine’s suspension of a physician’s license to practice medicine and its refusal to facilitate the production of certain medical records. The Board of Medicine imposed a 90-day suspension on a physician’s license, finding him professionally incompetent after complications had occurred during his treatment of a teenage girl. The physician argued that the Board did not have authority to discipline a license after only one "alleged simple negligence" case and because his license had lapsed prior to the suspension. The physician also sought the release of additional medical records. The court held that state law gave the Board of Medicine authority to suspend the physician’s license and refused to grant the release of additional medical records.

 

Longa v. Vicory

Longa v. Vicory

Peer Review

Longa v. Vicory, No. 83A01-0406-CV-233 (Ind. Ct. App. June 7, 2005)

The families
of six patients who were murdered by an ICU nurse over a two-year period
brought suit against the hospital board, the administrator, and two physicians
on the medical staff. The claim against the physicians was based on the Indiana
hospital licensing statute which they argued created a private cause of action
against the physicians for failing to provide proper peer review. The physicians
were part of the medical staff but did not care for the patients and were not
part of the hospital’s peer review committee.

The issue before the Court of Appeals was whether the Indiana statute imposed
a general duty on all members of the medical staff to assure proper peer review.
The court looked at the language of the statute and determined that it did
not create a duty from a physician to a patient. Rather, the statute made the
medical staff responsible to the board for peer review. The court also found
that the statute made members of peer review committees immune from liability.
Therefore, it would lead to an absurd result if members of peer review committees
were immune but other doctors could be sued. Thus, the Court of Appeals held
that the statute did not provide the families with a private cause of action
and dismissed the case.

 

Louisiana Dep’t of Health and Hosps. v. Center for Medicare and Medicaid Servs.

Louisiana Dep’t of Health and Hosps. v. Center for Medicare and Medicaid Servs.

IN THE UNITED STATES COURT OF APPEALS
FOR THE FIFTH CIRCUIT

__________________________

No. 02-60834
__________________________

United States Court of Appeals
Fifth Circuit
F I L E D
September 22, 2003

Charles R. Fulbruge III
Clerk

LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS,

Petitioner,

versus

CENTER FOR MEDICARE AND MEDICAID SERVICES; THOMAS A. SCULLY, in his
official capacity as Administrato r o f the Centers for Medicare and Medicaid Services; UNITED
STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES; TOMMY G.
THOMPSON, in his official capacity as Secretary of the U.S. Department of Health and Human
Services,

Respondents.

___________________________________________________

Appeal from the Administrato r of the Center for
Medicare and Medicaid Services
___________________________________________________

Before WIENER, CLEMENT , and PRADO, Circuit Judges.

EDITH BROWN CLEMENT, Circuit Judge:

This appeal arises following the dete rmination, by the Administrato r of the Center for Medicare

and Medicaid Services, that Rural Health Clinics in Lou isiana do not furnish “hospital services”, and

hence are not eligible for certain reimbursements. Because we find that interpretation to be

unreasonable, we REVERSE .

I. FACTS AND PROCEEDINGS

A.

(1)

Statuto ry and regulato ry background

The Medicaid pro gram

Medicaid is designed to enable states to offer medical assistance to certain low-income, elderly,

and disabled individuals whose income and resources ar e inadequate t o pay for necessary medical

services. See 42 U.S.C. § 1396 (2003). Under the Medicaid stat ute, the federal government and the

stat es cooperate and share the cost of providing medical assistance to Medicaid-eligible persons.

The Medicaid statute gives each state flexibility in designing and administering its own Medicaid

program. Under the statute, a st ate that elects to par ticipate in the program submits a “state p lan”

for review and approval by the S ecretary (“Secretary”) of the Department o f Health and Human

Services (“HHS”). See generally 42 U.S.C. § 1396a. A stat e that seeks to change its state plan may

submit a “state plan amendment” to the Center for Medicare and Medicaid Services (“CMS”) for

review and approval. See 42 C.F.R. §§ 430.14 – 430.15 (2002) (recor ding Secretary’s delegation of

authority for appro ving state plan amendments to CMS). CMS, on behalf of the Secretary, is

required to approve a state plan amendment that complies with all app licable statutes and regulations.

42 U.S.C. § 1396a(b). Once CMS approves a state plan amendment, t he Secretary pays the state a

percentage of the “total amount [the state] expended . . . as medical assistance under the State plan.”

42 U.S.C. § 1396b(a)(1). The percentage for Louisiana for the current fiscal year is 71.28%. See 66

Fed. Reg. 59790 (Nov. 30, 2001); see also 67 Fed. Reg. 69223 (Nov. 15, 2002) (raising Lou isiana’s

percentage to 71.63% for t he fiscal year start ing October 1, 2003).

(2)

Provisions for disproportionate share hospitals

In 1981, Congress added a requ irement that stat e plans include higher reimbursement rates for

“public hospitals and teaching hospitals which serve a large Medicaid and low income population [and

2

which] are part icularly dependent on Medicaid reimbursement . . . .” 42 U.S.C. § 1396a(a)(13)(A)

(not ing that a state plan must “provide for a public process for determination of rat es o f payment

under the plan for hospital services” under which “such rates take into acco unt . . . the situat ion of

hospitals which serve a disproportionate number of low-income patients with special needs”). To

meet the so-called disproportionate share (“DSH”) requirement, states must define and list DSH

hospitals that serve a greater percentage of Medicaid and low-income patients. 42 U.S.C. § 1396r-

4(a)(1); see also 42 U.S.C. § 1396r-4(b)(1) (restricting DSH designation to hospitals with low-

income ut ilizat ion rates exceeding 25% or to hospitals whose Medicaid inpatient ut ilizat ion rate is

at least one standard deviat ion above the mean Medicaid inpatient ut ilization rate of all in-stat e

hospitals receiving Medicaid payments). Stat es must provide an “approp riate increase in the rate o r

amount of payment for such services.” Id. Additionally, the statu te co ntemplates that

reimbursements will reflect not only the cost of caring for Medicaid recipients, but also the cost of

charity care given to uninsured patients. Id. § 1 396r -4(b)(3) (basing definition of “low-income

utilizat ion rate” in part on quant ity of charity care provided by the hospital). In 1987 and 1988,

Congress added specific requirements for states to comply with this general mandate through higher

payments to designated hosp itals.

(3)

State-specific and hospital-specific limits on DSH payment adjustments

In 1991, Congress directed the Secretary to determine stat e-specific limits on federal funding for

DSH payments for each fiscal year, using a statutory formula. See 42 U.S.C. § 1396r-4(f) (capp ing

Lou isiana’s DSH allotment for fiscal year 2002 at $631 million and for future fiscal years to the 2002

cap adjusted by the consumer price index). In 1993, Congress respo nded to report s that some

hospitals received DSH payment adjustments that exceeded “the net costs, and in some instances the

3

tot al costs, of operating the facilities,” by requiring hospital-specific limits o n DSH payments. See

H.R. REP. NO. 103-111, at 211-212 (1993), reprinted in 1993 U.S.C.C.A.N. 278, 538-539 (not ing

DSH payment adjustments seeped into state general funds to cover non-health care items including

road construction).

The hospital-specific limitat ions are at the heart of the dispute in this case. The 199 3 amendment

limits the amount of DSH payments to a specific hospital to

the costs incurred during the year of furnishing hospital services (as det ermined by
the Secretary and net of payments under this title, other than under this section, and
by uninsured patients) by the hospital to individuals who either are eligible for medical
assistance under the State plan or have no health insurance (or other source o f third
party coverage) for services provided during the year.

42 U.S.C. § 1396r-4(g)(1)(A) (emphasis added).

CMS has not promulgated any regulations specifically addressing the hospital-specific DSH limit

and thus has not addressed the use o f the term “hospital services” as it relates to those limits. In a

letter to State Medicaid directors dated August 17, 1994, the Health Care Financing Administrat ion

(“HCFA”), CMS’s predecessor agency, stat ed:

There are several impor tant considerations that must be made in det ermining the cost
of services under the DSH limit, whether for Medicaid or uninsured individuals. First,
the legislative history of this p ro vision makes it clear that S tat es may include both
inpatient and outpatient costs in the calculat ion o f the limit. Second, in defining
“costs of services” under this provision, HCFA would permit the State to use the
definition of allowable costs in its State plan, or any other definition, as long as the
costs determined under such a definition do not exceed the amounts that would be
allowable under the Medicare principles of cost reimbursement. . . . HCFA believes
this interpretation of the term “costs incurred” is reasonable because it provides
States with a great deal of flexibility up to a maximum standard that is widely known
and used in the determination of hospital costs.

4

Letter from Sally K. Richardso n, Department of Health & Human Services, to State Medicaid

Directors 3 (Aug. 17 , 1994) (emphasis added).

(4)

Rural Health Clinics (“RHCs”)

RHCs generally furnish “those diagnostic and therapeutic services and supp lies that are commonly

furnished in a physician’s office or at the entry point into the health care delivery system.” 42 C.F.R.

§ 491.9(c)(1). RHCs also provide “medical emergency procedures as a first response to common life-

threat ening injuries and acute illness and has available the drugs and biologicals commonly used in

life saving procedures, such as analgesics, anesthetics (local), antibiotics, anticonvulsants, antidotes

and emetics, serums and toxoids.” Id. 491.9(c)(3). Services in RHCs are furnished by a physician

or a mid-level practitioner, such as a nurse p ra ctitioner or physician assistant, acting under the

direct ion of a physician. Id. § 440.20(b)(1)-(3).

B.

Louisiana’s efforts to increase DSH payment adjustments

Lou isiana is largely rural and most of the rural areas are medically under-served. See 67 Fed.

Reg. 21962-67 (May 1, 2002) ( listing urban areas from the 2000 census). Recognizing that small

rural hospitals bear significant costs for the services they provide to low-income uninsured patients

through their “hospital-based” clinics,1 Lou isiana sought guidance from HHS as to how those costs

could be taken into account as part of a rural hospital’s DSH payment adjustment. In a January 19,

1999 letter U.S. Senat or John Breaux asked Donna Shalala, the then Secretary of HHS, to clarify

when RHC costs could be taken into account for DSH purposes. In her response, S ecretary Shalala

wrote:

1 RHCs are eligible to be “hospital-based RHCs” if certain conditions are met. See 42
C.F.R. § 413.65.

5

While I agr ee that a state has discretion to ‘license or formally approve’ a hospital-
based RHC as an outpatient hospital clinic for purpo ses of the Medicaid DSH
program, I [cannot] require that states consider t he co sts o f such a facility in
calculating DSH limits. Under applicable law, a St ate has the flexibility to include a
hospital-based RHC under the license of the hospital, to separately license a hospital-
based RHC, or to issue a license which recognizes the dual nature of the clinic as both
an outpatient hospital clinic and an RHC. Where a state has chosen to license these
clinics as hospital outpatient departm ent s, and they are certified as part of the
hospital, the state would be able to include the uncompensated care costs related to
RHC-provided hospital out pat ient services in the calculation of a hospital’s DSH
payment limit. However, if the state has decided that its hospital-based RHCs are to
be separately licensed, then the clinics’ costs cannot be included in DSH calculations.

. . .

Our underst anding is that Lou isiana law requires separate licensing of RHCs and does
not provide for any other formal approval process to designate outpatient hospital
facilities. Even if an RHC in Louisiana is based at the hospital and owned by the same
overall institution, its uncompensated care costs canno t be recognized for DSH
purposes because the services are not considered hospital services by Medicaid. The
services provided by these entities can only be considered RHC services, and these
clinics would receive cost-based reimbursement for their expenditures. This
distinction is critical because, as stated above, only uncompensated costs associated
with hospital services can be included in the Medicaid hospital specific DSH limit
calculation. However, if Louisiana were to create a process to licence (sic) or
“formally approve” hospital-based RHCs as hospital outpatient departments, then
the clinics’ uncompensated care costs associated with providing hospital outpatient
services could be included in the DSH calculation for their affiliated hospitals.

Letter from Donna E. Shalala, Secretary of Health & Human Services, to Senator John B. Breaux

1-2 (July 30, 1999) (emphasis added).

The Louisiana legislature responded to Secretary Shalala’s letter by immediat ely amending the

stat e stat ute governing RHC licensing requirements. The amendment pro vides:

[A] rural health clinic that meets the definition o f t he Health Care Financing
Administration as hospital-based and is operated by a rural hospital . . . shall not be

6

required to secure a separate license to receive cert ification by the He alth Care
Financing Administrat ion and designated reimbursement under Medicaid and
Medicare as long as the rural hospital meets stat e licensure requirements. Such
hospital shall assure that the clinic meet s all other requirements of [the rural health
clinic licensure sta tut ue], as well as any pursuant rules and regulations . . . .

LA. REV. STAT. ANN. § 40:2197(G) (West 2001).

Having amended state law, the State submitt ed a state plan amendment (“ SPA 01-03”), to CMS

for approval. SPA 01-03 implemented Sec retary Shalala’s guidance by providing t hat : “Any

uncompensated cost s of pro viding health care services in a rural health clinic licensed as part of a

small rural hospital . . . shall be considered outpatient hospital services in the calculation of

uncompensated costs.” Letter from David W. Hood, Secretary, Louisiana Department o f Health &

Hospitals, to Calvin G. Cline, Associate Regional Administrato r, Health Care Financing

Administration Att achment 4 (May 15, 2001) ( emphasis added).

CMS disapproved SPA 01-03 on August 15 , 2001. CMS referred to regulations defining

“outpatient ho sp ital services” in order to conclude that the services at issue did not fall within the

meaning of the term “hospital services”, as used in 42 U.S.C. § 1396r-4(g). See 42 C.F.R. 440.20(a).

Despite the fact that state law no longer required separate licensing of hospital-based RHCs, the

disapproval letter predicated its analysis on the seemingly inappo site observation that “a state may

not include costs or r evenues in the DSH calculation which are attributable to services rendered in

a separately licensed/certified entity, even if that entity is owned by the same institution.” Letter

from Thomas A. Scu lly, Administrato r for Centers for Medicare & Medicaid Services, to David W.

Hood, Secret ary, Louisiana Department of Health & Hospitals (Aug. 15, 2001) (emphasis added).

7

The State requested reconsideration, and a hearing officer convened an administrat ive hearing on

January 30, 2002. See 42 C.F.R. § 430.18 (providing for review of CMS disapprovals). The hearing

officer on June 7, 2002, recommended that the disapproval be upheld. The Administrat or on August

20, 2002, adopted the hearing officer’s recommendation and upheld the disapproval. The

Administrator st ated t hat because hospital services and RHC services are defined separat ely under

the Social Securit y Act and its implementing regulations, RHC services can never be considered

outpatient hospital services. Louisiana Stat e Plan Amendment 01-03, Doc. No. 2002-03 (Centers

of Medicare & Medicaid Services Aug. 19, 2002). The Administrato r reached that conclusion despite

the fact that oftent imes the clinics are licensed by the hospital and provide exactly the same types of

services as the hospital’s outpat ient emergency room, and the costs o f providing these services are

borne by the ho spitals. Louisiana timely appeals.

II. STANDARD OF REVIEW

This Court reviews the Administrato r’s decision disappro ving a state plan amendment under the

Administr at ive Procedure Act, 5 U.S.C. §§ 701 -706 (2003), to ensure that the decision was not

arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with law. See 5 U.S.C.

§ 706; Harris County Hosp. Dist. v. Shalala, 64 F.3d 220, 221 (5th Cir. 1995). In addition, t his

Court must defer to the Secretary’s interpretation o f Medicare legislation and its att endant

regulations—the Secretary’s interpre tat ion of Medicare regulations is given “contro lling weight unless

it is plainly erroneous or inconsistent with the regulation.” Id. If a statu te is involved and its meaning

is unambiguous, this Court must give effect to the intent o f Congress. See Chevron U.S.A., Inc. v.

Natural Res. Def. Council, Inc., 467 U.S. 837, 842 (1984). This Cou rt “shall have jurisdiction to

8

affirm the action of the Secretary or to set it as ide, in whole or in part.” 42 U.S.C. § 1316(a)(5)

(West 1991).

III. DISCUSSION

The dispositive issue in this case is whether the Administrator ’s disapproval of Louisiana’s

proposed st ate plan amendment was arbitrary or cap ricious, where the Administrato r determined

that t he term “hospital services” as used in 42 U.S.C. § 1396r-4(g) do es not include services

provided by RHCs.

A. Analysis

Louisiana and its amicus list three reasons why the Administra to r’s disapproval of SPA 01-03

was arbitrary and capricious: (1) the services provided by hospital-based RHCs that are not

separat ely licensed fall within the regulato ry definition of “outpat ient hospital services”; (2) the

Congressional purpose behind the DSH prog ram support s reimbursing hospital-based RHCs for

the cost o f caring for uninsured patients; and (3) CMS’s own regulations recognize hospital-based

RHCs are integral to their parent hospitals. CMS responds that the Administrator correctly found

that “outpat ient hospital services” and “rural health clinic services” are separate and distinct

catego ries of services.

(1) Whether services provided by hospital-based RHCs that are not separately licensed

fall within the regulatory definition of “outpatient hospita l services.”

The hosp ital-specific DSH limit allows reimbursement only of “the costs incurred during the

year o f furnishing hospital services . . . .” 42 U.S.C. § 1396r-4(g)(1)(A) (emphasis added).

Not ing that the agency has not defined “hospital services” for purpo ses of § 1396r-4(g), Louisiana

asserts that Congress intended the phrase to include both inpatient and outpatient hospital

9

services. In describing the 1993 DSH amendment, Congress wro te t hat the bill limits the amount

of DSH payment adjustments to the co sts “these facilities incur in furnishing inpatient or

outpatient services to Medicaid-eligible pat ients and uninsured patients, less payments from

Medicaid other than DSH payment adjustments” and uninsured pat ients. H.R. CONF. REP. NO.

103-213, at 835 (1993), reprinted in 1993 U.S.C.C.A.N. 1088, 1524 (emphasis added). CMS

concedes that the phrase “hospital services” in § 1396r-4(g)(1) (A) refers to both inpatient and

out patient hospital services.

HHS regulations define both “inpatient hospital services” and “outpat ient hospital services.”

“Outpat ient hospital services” is defined as “preventat ive, diagnostic, therapeut ic, rehabilitative,

or palliative services” that, among other things, are furnished by an institution that is “licensed or

formally approved as a hospital by an officially designated author ity for State standard-set ting . . .

.” 42 C.F.R. § 440.20. Louisiana asserts that services provided by hospital-based RHCs

indisputably satisfy the first part of the definition, being “preventat ive, diagnostic, therapeut ic,

rehabilitat ive, or palliative.” RHCs satisfy the “licensed o r formally approved” r equirement,

Louisiana maintains, because the clinics are not licensed independent ly from the parent hospitals.

Rather t han rebuffing Louisiana’s textual argument, with which it ag rees in part, CMS

analyzes the term “hospital services” with the premise that “outpat ient hospital services” and

“rural health clinic services” are mutually exclusive. CMS no tes: (1) federal statu tes and

regulations distinguish the terms in at least two places, see 42 U.S.C. §§ 1396d(a)(2)

(enumerating categories of medical assistance services, including outpat ient hospital services and

rura l health clinic services); 42 C.F.R. § 440.20 (defining each term); (2) unt il recently, RHC

services and outpat ient hospital services were subject t o two ent irely distinct payment reg imes,

10

see, e.g., 42 C.F.R. § 447.371 (designating reimbursement rules for ru ral health clinics); and (3)

Lou isiana itself recognizes in its state plan that RHC services and outpatient hospital services are

distinct categories of services. CMS assumes, without explanation, that any service that a RHC

render s may never be considered an outpatient hospital service even if the service fits w ithin the

regulato ry definition of “hospital out patient service”.

We agree with Lou isiana that a hospital-based RHC functions as a part of the hospital with which

it is affiliated. The hospital employs clinic personnel, pays the clinic’s bills, perfo rms quality

assurance, credent ials the physicians and physician assistants employed by the clinic, owns or leases

the building in which the clinic is located, handles payroll functions for the clinic, and provides

medical supplies to the clinic.

(2) Whether reimbursing hospital-based ru ral health clinics for the cost of caring for uninsured

pat ients fulfills the Congressional purpose of DSH payment ad justments.

Lou isiana argues that the Administrato r’s interpretation of § 1396r-4(g) conflicts with the broad

goal of the DSH program—to support hospitals that serve low-income patients. Louisiana claims

that Congress has, on multiple occasions, demonstrat ed an intention of broadly defining the DSH

program. See, e.g., H.R. Rep. No. 100-391, at 524-27 (1987) (demonstrating: (1) Congress’s

solicitude for the needs of rural hospitals by exempting them from certain requirements ot herwise

applicable to DSH ho spitals, and (2) Congress’s awareness of state plans that offer extra pa yments

to some hospitals because they provide “outpat ient services and outpatient pharmacy to Medicaid and

non-Med icaid eligible low-income pat ients”); H.R. REP. NO. 101-964, at 868, 871 (1990) (exp laining

new provision in § 1396r-4(c)(3) that allows additional DSH payments to designated hospitals to

finance services for Medicaid and low-income patients).

11

Lou isiana recognizes that when Congress amended the statute in 1993, it introduced a hospital-

specific DSH limit. But Louisiana emphasizes that the 1993 amendment’s use of the phrase “hospital

services” expanded the range of services covered by DSH by explicitly rejecting HCFA’s former

position that only inpatient services were covered. See, e.g., State of New York by Perales v. Bowen,

811 F.2d 776, 777-78 (2d Cir. 1987) (considering a co ntent ion by HCFA that DSH adjustment

payments could not include the costs of outpatient hospital service s). Lo uisiana contends that the

Administrato r’s interpretat ion—which precludes reimbursement to hospitals for uncompensated care

provided in their RHCs even though the same care provided to the same patients in a less clinically

appropriate and more cost ly emergency room would be covered—is antithetical to the intention of

Congress. Here to o it seems that Louisiana presents the stronger argument.

(3) Whether CMS’s ow n regulations recognize hospital based rural health clinics are

integral to their parent hospitals.

Lou isiana finally argues that t he regulations governing whether a RHC is hospital based2

demonstrate that qualifying clinics operate as any other hospital outpatient department. For instance,

the regulations require that, in order to be considered hospital based, a clinic must: have common

licensure with the parent facility; provide services that are fully integrated with the hospital’s services;

share income and expenses with the hospital; hold out to the public that it is part of the hospital; and

demonstrate it is under the contro l and ownership of the hospital. See 42 C.F.R. § 413.65(d)(3).

Louisiana also not es that the regulations have treat ed RHCs as hospital outpat ient departments

for Medicare reimbursement limitations. Unt il recent ly, Medicare reimbursed outpatient services on

2 The governing regulations refer to “provider based” RHCs. See, e.g., 42 C.F.R. §
413.65. Hospital based RHCs are a subset of provider based RHCs.

12

a reasonable-cost basis, except that certain reductions in t he calculation of reasonable cost s were

mandated. Under 42 C.F.R. § 413.124, “the reasonable costs of outpat ient hospital services (other

than capital-related costs of such services) are reduced by 5.8 percent.” Similarly, under 42 C.F.R.

§ 413.130, capital-related costs o f these hospitals are reduced by 10 percent. In the past, HCFA

required hospitals to treat their hospital-based RHCs as outpatient departments for reimbursement

purposes.

It seems clear that, without justification, the Administrato r’s decision made an assumption about

out patient hospital services and RHC services—that they are subst antially different—that HCFA’s

previous regulations showed to be unfounded.

B. The Administrato r’s decision was arbitrary and capricious

Lou isiana changed its law in response to, and it s underst anding is in accordance with, former

Secretary Shalala’s guidance . Lo uisiana eliminated Secretary Shalala’s primary objection to the

plan—separate licensing requirements for RHCs—and instead adopted a common licensure reg ime.

Not only were these changes substantial and made in good faith by the Louisiana legislature, but ,

when questioned directly at oral argument, counsel for CMS was unable to offer any other language

that Louisiana should have used to comply with Secretary Shalala’s letter.

CMS does not seriously dispute that RHCs provide medical services t raditionally provided in

hospitals. We agree with Louisiana that commonly-licensed RHCs, like traditional hospitals, provide

medical service that is “preventat ive, diagnostic, therapeutic, rehabilitative, or palliative,” 42 C.F.R.

§ 440.20, t hereby satisfying the first part of the definition o f “hospital services”.

The second part of the definition requires services to be furnished by an institu tion that is

“licensed or formally approved as a hospital by an officially designated authority for State standard-

13

setting . . . .” Id. The Administrato r adopt ed the recommendation of a hearing officer who ignored

the critical fact that Lou isiana, with an eye to this definition, enacted a system of common licensure

for hospital based RHCs. Whether medical care falls within the second part of the definition heavily

depends on the licensing scheme of the inst itu t ion furnishing the service. The Administrat or’s

assumpt ion— that the nature o f a service, and not the circumstances under which the service is

delivered, determines its categorization—ignores the common licensure scheme, the clea r textual

analysis offered by Lo uisiana, and the previous Medicare regulations that analyzed hospitals and

RHCs in a similar manner. Given t he Administrator’s decision was made without proper

consideration of the appropriate facts and contravenes prior regulations promulgated by the HCFA

itself, we hold that the Administrato r’s decision was arbitrary and capricious, and cannot stand.

IV. CONCLUSION

For the above stated reasons, we REVERSE the judgment of the Administrator.

14

Longmore v. Kingston Hospital,

Longmore v. Kingston Hospital,

Longmore v. Kingston Hospital,
N.Y. App. Div.,
June 5, 2003

A state appellate court in New York affirmed the dismissal of a physician’s
action
seeking a hearing and money damages after his work at a hospital was discontinued.
The hospital contracted with the physician’s employer to provide ER services
at the hospital. When the hospital did not renew the contract, the physician
(with courtesy staff privileges) requested a hearing regarding the termination
of his employment. The hospital denied the request, claiming it did not terminate
his employment because it did not employ the physician. The court agreed
with the hospital and further held the physician’s work was not terminated
because
his privileges were revoked, but because the employer ceased working at the
hospital. In addition, the court held that because the physician failed to
show that a
contract existed, no money damages could be awarded.

 

 

Louisiana Dep’t of Health and Hosps. v. Center for Medicare and Medicaid Servs.

Louisiana Dep’t of Health and Hosps. v. Center for Medicare and Medicaid Servs.

Louisiana Dep’t of Health and Hosps. v. Center for Medicare
and Medicaid Servs.,

No. 02-60834 (5th Cir. Sept. 22, 2003)

CMS
determined that Rural Health Clinics (RHCs) in Louisiana do not furnish "hospital
services" and thus are not entitled to a higher disproportionate share
reimbursement rate. The United States Court of Appeals for the Fifth Circuit
held that that determination was unreasonable.

The court found that hospital-based RHCs function as part
of the hospital because the hospital employs the clinic’s personnel, pays the
clinic’s bills, performs quality assurance and credentialing for the clinic,
owns or leases the clinic location, handles payroll functions and provides medical
supplies.

Longnecker v. Loyola Univ. Med. Ctr.

Longnecker v. Loyola Univ. Med. Ctr.

FIRST DIVISION
June 25, 2008

No. 1-06-1536

CONNIE LONGNECKER, Individually and as
Special Administrator of the Estate of
CARL LONGNECKER, Deceased,
Plaintiff-Appellant,

v.
LOYOLA UNIVERSITY MEDICAL CENTER, and
SIRISH PARVATHANENI, M.D.,
Defendants-Appellees.

Appeal from the
Circuit Court of
Cook County.

)
)
)
)
)
)
)
)
)
The Honorable
)
) Irwin J. Solganick,
Judge Presiding.
)

No. 02 L 007989

JUSTICE GARCIA delivered the opinion of the court.
Connie Longnecker, individually and as special administrator
of the estate of her husband Carl Longnecker, filed suit against
Dr. Sirish Parvathaneni and Loyola Medical Center, after Mr.
Longnecker died following an unsuccessful heart transplant.
During the procedure, Mr. Longnecker received a diseased
“hypertrophic heart.” He died four days later, never regaining
consciousness.
Dr. Parvathaneni acted as the “procuring” or “harvesting”
surgeon during the transplant. At trial, the plaintiff presented
two theories of liability: (1) Dr. Parvathaneni, as an agent of

No. 1-06-1536

Loyola, committed professional negligence where he failed to
properly test and visually inspect the donor heart, and failed to
diagnose it as having significant left ventricular hypertrophy
and coronary artery disease; and, (2) Loyola committed
institutional negligence by failing to ensure that Dr.
Parvathaneni understood his role as a procuring surgeon. The
jury found in favor of Dr. Parvathaneni and Loyola on the
professional negligence claim. The jury found against Loyola on
the institutional negligence claim and awarded the plaintiff $2.7
million.
Loyola filed a posttrial motion in which it argued it was
entitled to judgment notwithstanding the verdict (judgment
n.o.v.), or, in the alternative, a new trial, because (1) the
plaintiff failed to plead institutional negligence, (2) the
plaintiff failed to produce expert testimony to support
institutional negligence, (3) the plaintiff failed to establish
breach, (4) the plaintiff failed to establish causation, and (5)
the verdicts were inconsistent. The circuit court found the
verdict in favor of Dr. Parvathaneni to be irreconcilable with
the verdict against Loyola, reasoning if Dr. Parvathaneni had not
been negligent, Loyola’s failure to ensure he understood his role
could not have been the proximate cause of Mr. Longnecker’s
death. Therefore, the court decided the verdicts were
2

No. 1-06-1536

inconsistent. The court vacated the verdict against Loyola and
entered judgment for Loyola.
The plaintiff contends on appeal that the jury’s verdicts
are not inconsistent. She alternatively argues that if the
verdicts are inconsistent, the proper remedy is to order a new
trial on both causes of action.
Dr. Parvathaneni agrees the verdicts are not inconsistent.
In his brief, he points to the “wholly separate theories of
liability against Loyola as principal of Dr. Parvathaneni and
[liability against] Loyola for institutional negligence,” to
which two separate standards of care apply.
Loyola’s brief intimates that we need not determine whether
the verdicts are inconsistent if the circuit court’s grant of
judgment n.o.v. is proper for other reasons. Loyola focuses on
the circuit court’s finding that proximate cause was precluded
based on the verdict in favor of Dr. Parvathaneni to contend the
judgment n.o.v. was proper. Loyola also argues the judgment
n.o.v. was proper because the plaintiff failed to establish the
element of breach, and because the institutional negligence claim
was barred by the statute of limitations. In the alternative,
Loyola argues the circuit court correctly found the verdicts to
be inconsistent. Loyola concedes that if the verdicts are
inconsistent, the proper remedy is to order a new trial on both
3

No. 1-06-1536

claims.
For the reasons that follow, we hold the verdicts in this
case are not inconsistent, and that no other basis supports the
grant of judgment n.o.v. We therefore reverse the decision of
the circuit court of Cook County, and remand for further
proceedings.

BACKGROUND
Carl Longnecker suffered from numerous coronary ailments,
and, by age 58, had suffered three heart attacks.
In 2000, Mr. Longnecker became a patient of Dr. George
Mullen, a cardiologist at Loyola. Dr. Mullen told Mr. Longnecker
he needed a heart transplant, and placed his name on a donation
waiting list.
By 2001, Mr. Longnecker’s condition worsened. His “status”
on the donation waiting list went from “2 class” to “1B class,”
moving his name up the list. His chance of surviving one year
without a transplant was 30%.
On June 11, 2001, Mr. Longnecker was informed a potential
donor heart had been located. He went to Loyola and was prepared
for surgery.
A. Loyola Heart Transplantation Procedures
Loyola uses a team approach to heart transplantations. The
Loyola transplant team consists of a nurse coordinator and three
4

No. 1-06-1536

doctors: the transplant cardiologist, the procuring surgeon, and
the transplant surgeon.
The Regional Organ Bank of Illinois (ROBI) also plays a role
in Loyola’s heart transplantations. When a potential donor is
declared brain dead, ROBI gathers information about the donor,
including gender, age, and weight, the cause of death, and
whether the donor smoked, drank alcohol, or used narcotics. ROBI
may also order diagnostic tests of the donor’s heart. ROBI then
passes any relevant information to Loyola’s nurse coordinator,
who briefs the transplant cardiologist.
The transplant cardiologist first makes an evaluation, based
on the donor’s history and the results of any tests, to
preliminarily accept or decline the heart. If the heart is
preliminarily accepted, the procuring surgeon goes to the donor
hospital, where he or she opens the donor’s sternum and visually
inspects the heart and feels it for defects. Next, the procuring
surgeon makes the “final phone call” where he or she reports the
findings to the transplant surgeon, who decides whether to accept
or reject the heart. If the heart is accepted, the procuring
surgeon “cross-clamps” the donor heart, cutting off the blood
supply, and flushes it with a preservative solution. The heart
is transported to Loyola, where the transplant surgeon, who has
removed the patient’s “native” heart, transplants the donor
5

No. 1-06-1536

heart.
Time is of the essence in heart transplantations. A
preserved heart can remain viable for approximately four hours
after being removed from the donor’s body. Thus, the removal of
the donor heart and its transport to the recipient hospital must
be carefully coordinated with the removal of the recipient’s
native heart.
B. The Heart Transplantation in this Case
In this case, the nurse coordinator was Penny Pearson. Dr.
Mullen was the transplant cardiologist. The defendant, Dr.
Parvathaneni, was the procuring surgeon, and Dr. Foy, the
surgical director of the Loyola transplant team, was the
transplant surgeon.
The donor was a 46-year-old male who was declared brain dead
at Good Samaritan Hospital. The donor’s family informed ROBI he
smoked cigarettes and marijuana and drank alcohol regularly, and
that he may have used cocaine. The family also revealed the
donor was diagnosed with hypertension (high blood pressure) in
September 2000. He was “noncompliant” with treatment, meaning he
did not take medication regularly.
Based on the donor’s history, ROBI ordered diagnostic tests,
including an echocardiogram, the “gold standard” test for left
ventricle hypertrophy (the enlargement of the heart wall), and an
6

No. 1-06-1536

angiogram, the “gold standard” test for coronary artery disease
(plaque in the arteries). The donor’s level of troponin, a
substance that may be indicative of damaged heart muscle, was
also measured.
The echocardiogram revealed the donor’s left ventricle
measured 1.2 centimeters, meaning he suffered from “mild” left
ventricle hypertrophy. The angiogram revealed “mild” coronary
artery disease. The donor’s troponin level was elevated.
ROBI contacted Pearson with the above information. Pearson
then contacted Dr. Mullen, who, after evaluating the
echocardiogram and angiogram, and after discussing the matter
with Dr. Foy, preliminarily accepted the heart. Dr. Parvathaneni
then went to Good Samaritan in order to “visualize” the heart,
that is, to inspect it for congenital abnormalities and to
confirm the findings of the echocardiogram and angiogram. Dr.
Parvathaneni did not have any concerns about plaque or
hypertrophy in the heart. Dr. Parvathaneni called Dr. Foy and
told him the heart “look[ed] good” and was “suitable for
transplantation” from a surgical aspect. Dr. Foy accepted the
heart.
At 7:10 a.m., Dr. Parvathaneni cross-clamped the donor’s
heart, and removed it at 7:30 a.m. By 7:40 a.m., the heart was
in route to Loyola, where it arrived at 8:10 a.m.
7

No. 1-06-1536

At 7:48 a.m., while the donor heart was on its way to
Loyola, Dr. Foy placed Mr. Longnecker on a bypass machine. At
8:28 a.m., Mr. Longnecker’s native heart was cross-clamped and
removed. When Dr. Foy removed the donor heart from its
container, he immediately saw and determined by touch that it
suffered from left ventricular hypertrophy and coronary artery
disease. Dr. Foy wrote “Hypertrophic heart!” in his operative
note because the amount of hypertrophy was more than he expected
based on the results of the echocardiogram. Nevertheless, Dr.
Foy determined the heart was suitable for transplant, and
transplanted it. The heart, however, never functioned, and, on
June 15, 2001, Mr. Longnecker died. Had Mr. Longnecker survived,
his name would have been placed back on the heart donation
waiting list.
An autopsy revealed the donor heart weighed 492 grams,
whereas a normal heart weighs 300 grams. The heart’s left
ventricle measured two centimeters in thickness, indicating
“severe” hypertrophy. The heart also exhibited “moderate to
severe” coronary artery disease. The cause of death was
determined to be acute myocardial infarction, with left ventricle
hypertrophy being an indirect contributing cause.
C. Litigation
On June 24, 2002, the plaintiff filed a three-count
8

No. 1-06-1536

complaint against Loyola and Dr. Parvathaneni, alleging medical
negligence and wrongful death, and seeking recovery under the
Family Expense Act (750 ILCS 65/15 (West 2002)). The plaintiff
alleged that Loyola, by and through its agent, Dr. Parvathaneni:
“a. Failed to perform appropriate
testing of the donor heart;
b. Failed to perform appropriate visual
inspections of the donor heart;
c. Fail[ed] to diagnose significant
left ventricle hypertrophy in the donor heart
prior to transplantation;
d. Fail[ed] to diagnose significant
coronary artery disease in the donor heart
prior to transplantation; [and]
e. Otherwise deviated from the standard
of care.”
On June 10, 2003, the plaintiff filed an amended complaint
in which she named as additional defendants others involved in
the transplantation. Prior to trial, the additional defendants
were either granted summary judgment or voluntarily dismissed
from the case. The allegations against Loyola and Dr.
Parvathaneni were the same in both complaints. Neither complaint
expressly based Loyola’s liability on institutional negligence.
9

No. 1-06-1536

On November 29, 2005, one day prior to trial, Loyola filed a
motion in limine seeking to bar the plaintiff from presenting
evidence of Loyola’s institutional negligence because (1) the
plaintiff’s complaint did not allege institutional negligence,
(2) any institutional negligence claim would be time barred, and
(3) the plaintiff’s expert, Dr. James Avery, lacked the
appropriate foundation for his testimony regarding institutional
negligence. The circuit court denied the motion.
On November 30, 2005, the trial commenced. Dr. Foy
testified that he trained Dr. Parvathaneni, who had been a
cardiac fellow at Loyola, to procure hearts for transplantation.
Dr. Foy was “quite satisfied” that Dr. Parvathaneni both knew and
understood his responsibilities in terms of procuring hearts.
Thus, Dr. Parvathaneni remained on Loyola’s staff after his
fellowship completed.
Because Loyola used a team approach to organ procurement,
each team member was required to know his or her role and perform
that role. According to Dr. Foy, in Loyola’s system, the
procuring surgeon evaluates the donor heart and is involved in
making decisions regarding its suitability for transplant; the
procuring surgeon does more than simply remove the heart from the
donor’s body. The procuring surgeon is responsible for (1)
gathering and reviewing all of the available information about
10

No. 1-06-1536

the donor, (2) reviewing any echocardiograms and angiograms, (3)
visually inspecting the heart for trauma or abnormalities and
confirming or denying any abnormalities noted on the
echocardiogram or angiogram, and (4) feeling the heart. Dr. Foy
did not specify whether the procuring surgeon is required to feel
the heart prior to cross-clamp, or whether the examination need
be performed after removal. Dr. Foy’s “final decision” to accept
or reject the heart is based in large part on the procuring
surgeon’s findings.
In this case, by the time Dr. Foy removed the donor heart
from its container, he had already removed Mr. Longnecker’s
native heart. From the moment Dr. Foy held the donor heart, he
knew it had “significant” hypertrophy. Dr. Foy, however, decided
to proceed with the transplant. Although Dr. Foy’s deposition
testimony indicated that “at the time *** the donor heart[] is
brought on to the operative field the die is cast, you have no
choice but to implant that heart,” he testified at trial that he
had the option of using “a Jarvick type, total artificial heart.”
Dr. Parvathaneni, who is triple board certified in general
surgery, critical care, and cardiothoracic surgery, testified
that when he arrived at Good Samaritan to procure the heart, he
knew Drs. Foy and Mullen had already reviewed the results of the
echocardiogram and angiogram, and that Dr. Mullen had “evaluated
11

No. 1-06-1536

[the] heart and cleared it for transplant.” Dr. Parvathaneni
testified he also reviewed the echocardiogram and angiogram as
part of his duties.
Dr. Parvathaneni distinguished between two potential roles
of a Loyola transplantation team member: evaluating a heart for
transplant and examining a heart to be transplanted. He
testified it was his duty as the procuring surgeon to examine a
heart to be transplanted, not to evaluate a heart for transplant.
He did not consider himself capable of evaluating a heart for
transplant.
According to Dr. Parvathaneni, Loyola’s standard practice
required procuring surgeons to visually examine the heart and
manually assess it for hypertrophy and coronary artery disease
before removing the organ. Pursuant to this practice, Dr.
Parvathaneni visually inspected the heart while it remained in
the donor’s chest and felt it for plaque and hypertrophy. He
could not recall whether he could feel more hypertrophy or plaque
in the heart then indicated in the echocardiogram or angiogram
when he placed it in its container.
Dr. Parvathaneni acknowledged that hypertrophy can most
easily be felt after the heart is removed. However, Dr.
Parvathaneni testified he was not trained to manually inspect the
heart after removal. Rather, he was trained “to bring the organ
12

No. 1-06-1536

as fast as [he] could.” Dr. Parvathaneni explained, “Once we are
told to take the heart, we take the heart, bag it up and send it.
Time is of the essence, and they’re expecting the organ [at
Loyola].”
Dr. Mullen, the transplant cardiologist, testified he was
aware the donor was 46 years old and had a history of
uncontrolled hypertension. He was also aware the donor suffered
from “mild” hypertrophy and “mild” coronary artery disease. In
his opinion, it was proper to accept a heart with these
conditions. Dr. Mullen took “full responsibility” for accepting
the donor heart in this case.
Dr. Avery, a cardiovascular surgeon from the California
Pacific Medical Center, gave expert testimony on behalf of the
plaintiff. Prior to testifying, Dr. Avery reviewed depositions
from Drs. Foy, Mullen, and Parvathaneni, which served as the
bases for his opinions.
In Dr. Avery’s opinion, the standard of care required Dr.
Parvathaneni to review the patient’s medical and social history,
the echocardiogram and angiogram, to see and feel how the heart
worked in the donor’s chest, and to come to a conclusion
regarding whether to accept the heart. Dr. Parvathaneni’s
deposition testimony, however, indicated he did not believe he
was required to evaluate the heart at all; rather, he was sent to
13

No. 1-06-1536

Good Samaritan “to get the heart and bring it back.” Dr.
Parvathaneni’s deposition testimony was in conflict with
deposition testimony given by Drs. Foy and Mullen that described
Dr. Parvathaneni’s role as “enormous” in the evaluation of the
heart.
According to Dr. Avery, Dr. Parvathaneni deviated from the
standard of care by being unaware of “significant historical
items” related to the donor, including his history of
uncontrolled hypertension, history of cigarette smoking, and
potential cocaine use. Dr. Parvathaneni also deviated from the
standard of care by failing to perform a physical examination of
the donor heart after the heart was removed. If Dr. Parvathaneni
had done so, he would have found what Dr. Foy later found: “a
thick heart of significant hypertrophy and considerable plaque in
the coronaries.”
Dr. Avery additionally testified the standard of care
required Dr. Parvathaneni to understand his role in the
transplant as viewed by the other team members. However, Dr.
Parvathaneni’s deposition testimony indicated he failed to
understand his role, in deviation of the standard of care.
Regarding Loyola, Dr. Avery testified:
“Q. And in regards to the Loyola
transplant team did the standard of care
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No. 1-06-1536

require that they–did they have any
responsibility under the standard of care to
make sure that Dr. Parvathaneni understood
his role if they were going to send him to
get a heart?
A. Yes.
Q. And did Loyola deviate from the
standard of care in that regard?
MR. PATTERSON [Counsel for Loyola]:
Objection your Honor, motion in limine.
THE COURT: Overruled.
A. [Dr. Avery]: In this regard I
believe they did.
Q. In what manner?
A. Well, basically everybody needs to
be on the same page in terms of what each
team member’s role is in the team.”
In Dr. Avery’s opinion, had Dr. Parvathaneni fulfilled his
responsibilities pursuant to the standard of care, and had Loyola
fulfilled its responsibilities in ensuring Dr. Parvathaneni knew
his role, the heart would not have been transplanted.
Dr. Robert Higgins, the chairman of cardiovascular and
thoracic surgery and the director of the Heart Transplant and
15

No. 1-06-1536

Mechanical Assist Device Program at Rush University Medical
Center, testified as an expert on behalf of Loyola. Dr.
Higgins’s opinion, to a reasonable degree of scientific
certainty, was that the donor heart was suitable for
transplantation. The echocardiogram showed only mild
hypertrophy, the angiogram showed only mild coronary artery
disease, and the donor’s possible cocaine use was not a factor in
the donor’s death. The heart was also visually suitable for
transplantation. Dr. Higgins, however, testified he would not
transplant a heart with two-centimeter hypertrophy and severe
coronary artery disease.
Dr. Alfred Carl Nicolosi testified as an expert on behalf of
Dr. Parvathaneni. According to Dr. Nicolosi, Dr. Parvathaneni
complied with the standard of care in his role as a procuring
surgeon because he reviewed the echocardiogram and the angiogram,
and conducted a visual inspection and physical examination of the
heart. According to Dr. Nicolosi, the donor heart was acceptable
for transplant, and none of Dr. Parvathaneni’s actions caused Mr.
Longnecker’s death. According to Dr. Nicolosi, the left
ventricle of the donor heart measured two centimeters at the
autopsy because of swelling, not because of hypertrophy.
At the jury instruction conference, Loyola unsuccessfully
objected to instructions on Loyola’s institutional negligence.
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No. 1-06-1536

The jury was instructed, in part:
“The plaintiff claims that Carl
Longnecker died and that defendants Dr.
Parvathaneni and Loyola *** were negligent in
one or more of the following respects: Failed
to properly evaluate the donor heart; failed
to perform an appropriate physical
examination of the donor heart; failed to
communicate significant problems with the
donor heart after physical examination; and
failed to reject the donor heart for
transplantation.
The plaintiff further claims that
defendant Loyola *** was negligent in one or
more of the following respects: Failed to
ensure that Dr. Parvathaneni understood his
role as a procuring surgeon.
Negligence by a hospital is the failure
to do something that a reasonably careful
hospital would do or the doing of something
that reasonably careful hospital would not do
under the circumstances similar to those
shown by the evidence.
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No. 1-06-1536

The law does not say how a reasonably
careful hospital would act under the
circumstances, that is for you to decide.”
The jury was not instructed that it could return a verdict
in favor of Dr. Parvathaneni only if it also found in favor of
Loyola. In fact, the jury instructions allowed the jury to find
the way it did.
After initially indicating it could not reach a verdict, the
jury found for Dr. Parvathaneni and Loyola on the professional
negligence claim, and against Loyola on the institutional
negligence claim. The jury assessed $2.7 million in damages.
On Loyola’s motion for judgment n.o.v., the circuit court
found the verdicts inconsistent, and vacated the verdict against
Loyola. The circuit court stated:
“If the institutional negligence in this
case is based specifically on the conduct of
Dr. Parvathaneni in that he did not
understand what his role was and was not–and
that Loyola did not make sure he understood
his role, well, if the jury found that he
wasn’t negligent, then, you know, there was
nothing wrong with what he did and whether he
personally did not understand his role or
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No. 1-06-1536

whether Loyola didn’t see that he understood
his role doesn’t matter. He didn’t do
anything that caused harm to [Mr.
Longnecker].
If his actions were not a proximate
cause of injury to Mr. Longnecker, even if he
was negligent, then if anything that he did
didn’t cause Mr. Longnecker’s death, then,
you know, the failure by Loyola to see that
he understood what he was doing or knew what
he was doing doesn’t really matter. Nothing
he did was the cause of the injury to Mr.
Longnecker. So they really are
inconsistent.”
The court entered judgment in favor of both defendants.
This timely appeal followed.
ANALYSIS
In medical negligence cases, a hospital may face liability
under two separate and distinct theories: (1) vicarious liability
for the medical negligence of its agents or employees; and (2)
liability for its own institutional negligence. Darling v.
Charleston Community Memorial Hospital, 33 Ill. 2d 326, 211
N.E.2d 253 (1965), cert. denied, 383 U.S. 946, 16 L. Ed. 2d 209,
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No. 1-06-1536

86 S. Ct. 1204 (1966).
In a professional negligence case, the standard of care
requires the defendant to act with “the same degree of knowledge,
skill and ability as an ordinarily careful professional would
exercise under similar circumstances.” Advincula v. United Blood
Services, 176 Ill. 2d 1, 23, 678 N.E.2d 1009 (1996). Generally,
“expert testimony is necessary in professional negligence cases
to establish the standard of care.” Snelson v. Kamm, 204 Ill. 2d
1, 43-44, 787 N.E.2d 796 (2003). “[E]xpert testimony is needed
*** because jurors are not skilled in the practice of medicine
and would find it difficult without the help of medical evidence
to determine any lack of necessary scientific skill on the part
of the physician.” Walski v. Tiesenga, 72 Ill. 2d 249, 256, 381
N.E.2d 279 (1978).
Institutional negligence involves an analogous standard of
care; a defendant hospital is judged against what a reasonably
careful hospital would do under the same circumstances. Illinois
Pattern Jury Instructions, Civil, No. 105.03.01 (1995). See
generally Jones v. Chicago HMO Ltd. of Illinois, 191 Ill. 2d 278,
294-99, 730 N.E.2d 1119 (2000). Under this theory of liability,
however, “the standard of care *** may be shown by a wide variety
of evidence, including, but not limited to, expert testimony,
hospital bylaws, statutes, accreditation standards, custom and
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No. 1-06-1536

community practice.” Jones, 191 Ill. 2d at 298. “[T]he
institutional negligence of hospitals can also be determined
without expert testimony in some cases.” Jones, 191 2d at 296.
The concept of proximate cause is the same under
professional and institutional negligence. However, consistent
with the help lay jurors need “to determine any lack of necessary
scientific skill on the part of the physician” (Walski, 72 Ill.
2d at 56), “[t]he proximate cause element of a medical
malpractice case must be established by expert testimony to a
reasonable degree of medical certainty.” (Emphasis added.)
Krivanec v. Abramowitz, 366 Ill. App. 3d 350, 356-57, 851 N.E.2d
849 (2006). We are aware of no authority that imposes a similar
rule that proximate cause be established to a reasonable degree
of medical certainty in an institutional negligence case.
However, an institutional negligence case may present where
professional and institutional standards of care are so
intertwined that proximate cause is required to be shown to a
reasonable degree of medical certainty. The case before us is
not such a case. Nor does Loyola contend otherwise.
In this case, the jury rejected the plaintiff’s contention
that Dr. Parvathaneni (and, vicariously, Loyola) was
professionally negligent. The plaintiff does not challenge this
finding on appeal. The jury accepted the plaintiff’s contention
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No. 1-06-1536

that Loyola was institutionally negligent. The circuit court,
however, concluded the jury’s findings were inconsistent, granted
Loyola’s motion for judgment n.o.v., and vacated the verdict.
The plaintiff challenges this ruling.
A motion for judgment n.o.v. should be entered “only in
those cases in which all of the evidence, when viewed in its
aspect most favorable to the opponent, so overwhelmingly favors
movant that no contrary verdict based on that evidence could ever
stand.” Pedrick v. Peoria & Eastern R.R. Co., 37 Ill. 2d 494,
510, 229 N.E.2d 504 (1967). Our standard of review is de novo.
York v. Rush-Presbyterian-St. Luke’s Medical Center, 222 Ill. 2d
147, 178, 854 N.E.2d 635 (2006).
I. Institutional Negligence
In support of affirming the trial court’s decision, Loyola
puts forth three arguments: (1) the jury should not have
considered the institutional negligence claim because the claim
was time barred; (2) judgment n.o.v. was proper because the
plaintiff failed to establish breach; and, (3) judgment n.o.v.
was proper because the plaintiff failed to establish proximate
cause.
Before addressing the merits of Loyola’s contentions, we
address the plaintiff’s assertion that Loyola has waived the
first two contentions, if not also the third, because it failed
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No. 1-06-1536

to obtain a conditional ruling in the circuit court in violation
of section 2-1202(f) of the Code of Civil Procedure, which
requires the circuit court to “rule conditionally on the other
relief sought [in a posttrial motion].” 735 ILCS 5/2-1202(f)
(West 2006). Loyola’s posttrial motion, which raised the issues
of timeliness, breach, and proximate cause, did not seek other
forms of relief. Rather, Loyola’s posttrial motion set forth
alternative bases for the same relief–judgment n.o.v.
Consequently, Loyola’s alternative bases for upholding the
judgment n.o.v. are not waived. Varady v. Guardian Co., 153 Ill.
App. 3d 1062, 1070, 506 N.E.2d 708 (1987); Ralston v. Plogger,
132 Ill. App. 3d 90, 97, 476 N.E.2d 1378 (1985). We address each
in turn.

A. Time Barred
Loyola points out the plaintiff’s original and amended
complaints did not specifically allege Loyola breached any
independent duty of care and, in its view, only alleged Loyola
was vicariously liable for Dr. Parvathaneni’s alleged
malpractice. Loyola argues, “Even assuming that Plaintiff
attempted to amend her complaint at [a later date], any claim of
institutional negligence against Loyola would be time barred.”
Loyola points out the statute of limitations for a medical
malpractice claim is two years (735 ILCS 5/13-212(a) (West
23

No. 1-06-1536

2004)), and argues any institutional negligence claim would not
“relate back” to the original complaint under section 2-616(b) of
the Code of Civil Procedure (735 ILCS 5/2-616(b) (West 2004)).
Section 2-616(b) provides:
“The cause of action, cross claim or
defense set up in any amended pleading shall
not be barred by lapse of time under any
statute *** prescribing or limiting the time
within which an action may be brought or
right asserted, if the time prescribed or
limited had not expired when the original
pleading was filed, and if it shall appear
from the original and amended pleadings that
the cause of action asserted, or the defense
or cross claim interposed in the amended
pleading grew out of the same transaction or
occurrence set up in the original pleading
***.” 735 ILCS 5/2-616(b) (West 2004).
Loyola mistakenly relies on section 2-616(b) and
institutional negligence cases addressing the relation-back
doctrine. See, e.g., Frigo v. Silver Cross Hospital & Medical
Center, 377 Ill. App. 3d 43, 62, 876 N.E.2d 697 (2007)
(plaintiff’s negligent credentialing claim related back to her
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No. 1-06-1536

original pleading specifically alleging the hospital committed
negligence); Weidner v. Carle Foundation Hospital, 159 Ill. App.
3d 710, 713, 512 N.E.2d 824 (1987) (plaintiff’s allegation that
the hospital breached its institutional duty of care did not
relate back to her original complaint alleging the hospital was
vicariously liable for the doctor’s malpractice). The relation-
back provision of section 2-616(b), by its very terms, applies
only in cases where “cause[s] of action, cross claim[s] or
defense[s]” are raised beyond the limitations period in “any
amended pleading.” 735 ILCS 5/2-616(b) (West 2004); Porter v.
Decatur Memorial Hospital, 227 Ill. 2d 343, 882 N.E.2d 583
(2008). In this case, the plaintiff did not raise any new claim
against Loyola in an amended pleading. Rather, the plaintiff’s
original and amended complaints, both filed within the two-year
limitations period, contained the same allegations against
Loyola, and no other amended pleadings were filed. Simply
stated, the relation-back doctrine has no application in this
case.
What is relevant, however, is whether the plaintiff’s timely
filed amended complaint contained sufficient facts to put Loyola
on notice that the plaintiff sought to hold it liable for
institutional negligence. The plaintiff’s amended complaint
alleged Loyola and Dr. Parvathaneni failed to properly test,
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No. 1-06-1536
inspect, and diagnose the donor heart, and that both defendants
“[o]therwise deviated from the standard of care.” Although the
amended complaint did not expressly assert an institutional
negligence claim against Loyola, Loyola was on notice of this
theory of liability long before the commencement of trial. In
her Supreme Court Rule 213 (210 Ill. 2d R. 213) response, the
plaintiff disclosed Dr. Avery’s opinion on this very point.
“9. Defendant Loyola University Medical
Center, as an institution and through the
physicians practicing within the heart
transplant unit, had a duty to ensure that
each physician and participant in the heart
transplant team understood his or her role
and what was expected of him or her in the
assessment of the donor heart for transplant.
This was a deviation from the standard of
care on the part of Defendant Loyola
University Medical Center.”
Loyola’s motion in limine to bar Dr. Avery from testifying
about institutional negligence confirms that Loyola understood
that the plaintiff was proceeding under this separate theory of
liability.
We reject Loyola’s contention that the plaintiff’s

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No. 1-06-1536
institutional negligence claim was time barred.
B. Breach of Duty
In an institutional negligence case, “[a] hospital owes a
duty to its patients to exercise reasonable care in light of
apparent risk.” Andrews v. Northwestern Memorial Hospital, 184
Ill. App. 3d 486, 493, 540 N.E.2d 447 (1989), citing
Ohligschlager v. Proctor Community Hospital, 55 Ill. 2d 411, 303
N.E.2d 392 (1973). Here, the “apparent risk” was that a donor
heart with significant hypertrophy would be accepted for
transplantation. In order to avoid this risk, the plaintiff
asserts Loyola had a duty to ensure that each member of the heart
transplant team was fully aware of his role in evaluating the
donor heart for transplantation.1
According to the plaintiff, Dr. Parvathaneni should have
been informed that his role, as part of the transplant team,
included evaluating the heart for transplantation after
harvesting, not simply examining the heart while in the donor.
Had Dr. Parvathaneni evaluated the heart after harvesting, he
likely would have made the same observation Dr. Foy made after

1 Loyola makes no claim that the standard of care, itself,
was not established by the evidence in light of Dr. Foy’s
testimony that the procuring surgeon is charged with evaluating
the donor heart for transplantation.
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No. 1-06-1536
first observing the donor heart, that it was a “Hypertrophic
heart!” Dr. Avery, the plaintiff’s expert, explained that had
Dr. Parvathaneni evaluated the heart after it was removed he
would have found: “a thick heart of significant hypertrophy and
considerable plaque in the coronaries.” Dr. Parvathaneni
testified that hypertrophy can most easily be felt after the
heart is removed; he, however, was not trained to manually
inspect the heart after removal. After removal, his role was “to
bring the organ as fast as [he] could” to Loyola. According to
Dr. Foy’s deposition testimony, he was “surprised” by Dr.
Parvathaneni’s description of his role because Dr. Parvathaneni
played a much greater role in evaluating the donor heart. In his
deposition, Dr. Mullen characterized Dr. Parvathaneni’s role in
evaluating the donor heart as “enormous.” As Dr. Avery
testified, Loyola owed a duty of reasonable care to Mr.
Longnecker to ensure that before his native heart was removed,
the donor heart was evaluated as acceptable for transplantation
by each member of the transplant team.
Against this record, Loyola makes three arguments to
challenge the jury’s finding of breach of duty.
First, Loyola argues there is no evidence it knew or should
have known about Dr. Parvathaneni’s noncompliance with transplant
procedures. Loyola cites Pickle, 106 Ill. App. 3d 734, 435

28

No. 1-06-1536
N.E.2d 877, Reynolds v. Mennonite Hospital, 168 Ill. App. 3d 575,
522 N.E.2d 827 (1988), and Rohe v. Shivde, 203 Ill. App. 3d 181,
560 N.E.2d 1113 (1990) as support.
In Pickle, the plaintiff sued the doctor and the hospital,
alleging he suffered injuries as a result of electroconvulsive
therapy. The plaintiff specifically alleged the doctor
administered the therapy in a manner that did not comply with the
hospital’s policies, and the hospital allowed the procedure to be
performed in violation of its policies. The circuit court
dismissed the complaint and we affirmed. We held the complaint
was properly dismissed because the plaintiff failed to allege the
hospital knew or should have known the doctor would violate its
policies. Our decision in Holton v. Resurrection Hospital, 88
Ill. App. 3d 655, 659, 410 N.E.2d 969 (1980), which held that a
hospital has a duty to use reasonable care to discern the medical
qualifications of those practicing within the hospital and that a
hospital breaches that duty where it allows a doctor to practice
where it knows or should know the doctor is unqualified, provided
the authority for our holding. We refused to “recognize the
existence of a duty on the part of the hospital’s administration
to insure that each of its staff physicians will always perform
his duty of due care,” because that would amount to requiring the
hospital to act as an insurer of a patient’s safety. Pickle, 106

29

No. 1-06-1536
Ill. App. 3d at 739.
Similar claims were raised in Reynolds and Rohe. Rohe, 203
Ill. App. 3d at 200 (alleging the defendant hospital allowed a
pediatrician to practice where the pediatrician violated several
hospital policies); Reynolds, 168 Ill. App. 3d at 577 (alleging
the defendant hospitals failed to review and supervise the
doctors’ work where the doctors misdiagnosed the plaintiffs and
performed unnecessary surgery). In both cases, we held the
hospitals were entitled to summary judgment because the
plaintiffs failed to allege the hospitals were aware of the
doctors’ actions. Rohe, 203 Ill. App. 3d at 203; Reynolds, 168
Ill. App. 3d at 578-79.
Pickle, Reynolds, and Rohe do not control this case. Each
of the three cases involved a “rouge” doctor practicing medicine
in violation of the policies set forth by the hospital.
Unaddressed in those cases is the issue here–whether the
hospital adequately informed a doctor of his duties while working
as a member of a team of doctors. The allegation against Loyola
is not that Dr. Parvathaneni harvested hearts in violation of
Loyola’s policies. Rather, the allegation is that Loyola never
informed Dr. Parvathaneni that his duty as a harvesting surgeon
encompassed “evaluating a heart for transplantation.” The
plaintiff’s claim of reasonable care owed by Loyola was not to

30

No. 1-06-1536
insure that each member of the heart transplant team will always
perform his duty of reasonable care to his patient; rather, the
plaintiff contends Loyola breached its duty to ensure Dr.
Parvathaneni knew his role as part of the heart transplant team
was not simply to examine but to evaluate the donor heart.
Second, Loyola argues the plaintiff “failed to proffer any
evidence that if Loyola had done something differently with
respect to the training or supervision of Dr. Parvathaneni, his
alleged noncompliance would have been discovered.” Loyola’s
contention, by linking Loyola’s shortfall on “training or
supervision of Dr. Parvathaneni” to the discovery of the alleged
noncompliance, misses the point. As we have made clear above, it
is not the discovery of Dr. Parvathaneni’s “alleged
noncompliance” with a Loyola policy that is at issue; rather, at
issue is Loyola’s alleged failure to ensure Dr. Parvathaneni was
aware of its policy that the procuring surgeon had a role in
evaluating the heart for transplantation.
Finally, Loyola argues Dr. Avery’s testimony was conclusory.
Dr. Avery testified Dr. Parvathaneni’s deposition testimony
conflicted with that of Drs. Foy and Mullen regarding the role of
the procuring surgeon. According to Dr. Avery, Loyola breached
the standard of care because “everybody needs to be on the same
page in terms of what each team member’s role is in the team.”

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No. 1-06-1536
According to Loyola, “To sustain Plaintiff’s burden, Dr. Avery
was required to explain specifically how Loyola allegedly
breached the applicable standard of care–to identify what Loyola
failed to do that a ‘reasonably careful’ hospital would have done
under similar circumstances to ensure that individual members of
the Transplant Team understood their respective roles.” Loyola
again relies on Reynolds.
As discussed above, Reynolds affirmed summary judgment in
favor of the defendant hospitals because the plaintiffs failed to
establish the defendant hospitals knew or had reason to know of
the doctors’ alleged malpractice. The court also addressed
whether testimony from the plaintiffs’ expert was sufficient to
establish the hospitals’ knowledge. We held it was not.
Although the expert opined that the hospitals should have known
of the doctors’ improper diagnoses of thoracic outlet syndrome,
the plaintiffs failed to allege any facts “to substantiate that
opinion.” Reynolds, 168 Ill. App. 3d at 579. Thus, in Reynolds,
the expert asserted a conclusion without factual support that the
hospital should have known of the doctors’ noncompliance through
proper review.
Here, the facts underlying Dr. Avery’s opinion go directly
to the claimed breach by Loyola of its duty of reasonable care
owed to Mr. Longnecker that each team member evaluate the heart

32

No. 1-06-1536
for transplantation. Dr. Parvathaneni testified he was not
trained to “evaluate” the donor heart for hypertrophy even though
such an evaluation could be quickly made based on Dr. Foy’s
immediate observation after removing the donor heart from the
transport container that it was a “Hypertrophic heart!” Drs. Foy
and Mullen each provided deposition testimony that Dr.
Parvathaneni had an enormous role in evaluating the donor heart
for transplantation. This enormous role Dr. Parvathaneni was
expected to play in evaluating the donor heart for
transplantation is confirmed by Dr. Foy’s decision to remove Mr.
Longnecker’s heart before he personally viewed the donor heart.
Dr. Avery’s opinion that Loyola breached the standard care
by failing to ensure that each member of the transplant team
evaluated the donor heart had sufficient factual support in the
record to establish that Loyola breached its duty of care to Mr.
Longnecker.

C. Proximate Cause
Loyola next argues the plaintiff failed to establish
proximate cause. Loyola argues “there was no evidence that if
Loyola had done something differently with respect to the
training or supervision of Dr. Parvathaneni, then Dr.
Parvathaneni and Dr. Foy would have rejected the donor heart for
transplantation in Mr. Longnecker.” As authority for its “no

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No. 1-06-1536
proximate cause” contention, Loyola relies on Snelson v. Kamm,
204 Ill. 2d 1, 787 N.E.2d 796 (2003), a case not involving a
claim of institutional negligence.
In Snelson, under Dr. Kamm’s care, Snelson underwent a
“radiological procedure known as an aortogram or aroteriogram,
[performed by a radiologist practicing at the hospital,] to
determine the location of arterial blockages.” Snelson, 204 Ill.
2d at 10. The procedure was terminated because of the difficulty
in inserting “the guide wire.” Snelson, 204 Ill. 2d at 10. Dr.
Kamm, a general surgeon, was informed that the test was not
completed and that Snelson complained of back and abdominal pain
following the unsuccessful procedure. Snelson, 204 Ill. 2d at
11. After ameliorative treatments over the course of a day and a
half to address Mr. Snelson’s severe abdominal pain were
exhausted, Dr. Kamm performed emergency exploratory surgery,
which revealed portions of the small and large bowel loops were
dead. At trial, the radiologist opined that the “unsuccessful
*** aortogram caused the death of portions of Snelson’s
intestine[s].” Snelson, 204 Ill. 2d at 15.
The action against the hospital was based on Snelson’s claim
that the attending nurses negligently failed to inform Dr. Kamm
that they had inserted a catheter before Dr. Kamm ordered one and
that Snelson was experiencing high levels of pain. This, Snelson

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No. 1-06-1536
contended, affected the treatment he received from Dr. Kamm.
Snelson, 204 Ill. 2d at 13. After a verdict was returned against
Dr. Kamm and the hospital, the circuit court entered a judgment
n.o.v. for the hospital, finding no causal connection between the
alleged failures of the nurses and the medical treatment rendered
by Dr. Kamm. Snelson, 204 Ill. 2d at 13. The appellate court
affirmed. The supreme court granted leave to appeal.
The supreme court began its discussion of Snelson’s claim
that the judgment n.o.v. was error with observations based on the
record evidence. “Snelson acknowledges that he presented no
expert testimony indicating that [the hospital’s] conduct was a
proximate cause of his injury. He also acknowledges that Kamm
testified that no act or omission of the nursing staff affected
his course of treatment ***. Nevertheless, Snelson argues that a
question of fact as to proximate cause was sufficiently
established by the evidence.” Snelson, 204 Ill. 2d at 42.
Here, Loyola does not assert, nor can it based on the record
before us, that the plaintiff acknowledges similar shortfalls in
the evidence. Snelson is thus factually distinguishable. We
nonetheless address Loyola’s contention that under a Snelson-type
analysis, proximate cause was not shown here.
According to Loyola, as to Dr. Foy’s decision to transplant
the donor heart, the record evidence supports but one conclusion:

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No. 1-06-1536
“[E]ven though the donor heart had more hypertrophy than Dr. Foy
expected based on the echocardiogram, Dr. Foy decided that the
heart was acceptable for transplant in Mr. Longnecker.” Thus,
Loyola argues, because the donor heart was found acceptable for
transplantation by Dr. Foy, there was no causal connection
between Dr. Parvathaneni’s failure to evaluate the heart after
harvest and Dr. Foy’s decision to transplant the donor heart.
It is true that Dr. Foy testified that he decided the heart
was suitable for transplant and that he had the alternative
option of using an artificial heart if he found the donor heart
unacceptable. Loyola ignores, however, that the jury also had
before it Dr. Foy’s deposition testimony that once he removed Mr.
Longnecker’s native heart, “the die is cast, [there is] no choice
but to implant [the donor] heart.” The discovery by Dr. Foy that
the donor heart was hypertrophic was simply too late once the
donor heart was on the “operative field.” The jury also heard
the testimony of Dr. Higgins, an expert called on behalf of
Loyola, that he would not transplant a heart with two-centimeter
hypertrophy and severe coronary artery disease. At the autopsy,
the donor heart measured two centimeters in thickness at the left
ventricle and exhibited “moderate to severe” coronary artery
disease.
This conflict in the evidence made it a jury question

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No. 1-06-1536
whether the alleged breach of Loyola’s institutional standard of
care proximately caused the death of Mr. Longnecker.
Our conclusion that proximate cause was a question of fact
for the jury is supported by the conclusion reached by the
supreme court in Jones on the issue of proximate cause in an
institutional negligence case. In Jones, in response to Chicago
HMO’s argument that there was no causal connection between
Shawndale’s claim and the failure of Chicago HMO to schedule a
needed appointment in which Shawndale’s illness would have been
discovered, the court observed: “We can easily infer from this
record that Dr. Jordan’s failure to see Shawndale resulted from
an inability to serve an overloaded patient population. A lay
juror can discern that a physician who has thousands more
patients than he should will not have time to service them all in
an appropriate manner.” Jones, 191 Ill. 2d at 301. This
reasonable inference, along with additional evidence in the
record that Chicago HMO was soliciting more patients, the supreme
court concluded, presented a material question of fact to
overcome summary judgment “on Jones’ claim of institutional
negligence for assigning too many patients to Dr. Jordan.”
Jones, 191 Ill. 2d at 304.
Likewise here, the jury could have inferred that Dr. Foy
removed Mr. Longnecker’s native heart, not because it was in

37

No. 1-06-1536
worse condition than the hypertrophic heart of the donor but
because he relied on Dr. Parvathaneni to have informed him if the
donor heart were hypertrophic, that is, to a greater degree than
indicated in the diagnostic tests of the donor. As the plaintiff
claims, had Loyola properly conveyed to Dr. Parvathenani that as
part of the transplant team his duties included evaluating the
donor heart after harvest, thus leading to the discovery of the
significant hypertrophy in the donor heart, “then Dr. Foy would
have rejected the donor heart for transplantation in Mr.
Longnecker.” That the severity of hypertrophy in the donor
heart, detected by Dr. Foy immediately upon removing the heart
from the transport container, was a shock to Dr. Foy is revealed
by the exclamation notation of “Hypertrophic heart!” in his
operating notes. The jury was not required to believe Dr. Foy’s
testimony in court that he found the heart acceptable for
transplantation over his deposition testimony that once he
removed Mr. Longnecker’s native heart, he “had no choice but to
implant [the donor] heart.” The jury was free to draw the
inference from the evidence that Dr. Foy would not have
“implant[ed] that heart” had he had a real choice, which a
properly trained Dr. Parvathenani would have given him.
Accordingly, there was a causal connection between Loyola’s
failure to ensure that the entire transplant team was “on the

38

No. 1-06-1536
same page” and Mr. Longnecker’s death, caused by the
transplantation of a nonfunctioning heart.
Finally, the circuit court’s conclusion that a verdict in
favor of Dr. Parvathaneni precluded a proximate cause showing as
to the institutional negligence claim, in the context of this
case, is, simply put, wrong. Our supreme court has expressly
stated: “Liability is predicated on the hospital’s own
[institutional] negligence, not the negligence of the physician.”
Jones, 191 Ill. 2d at 292. “[T]he tort of institutional
negligence ‘does not encompass, whatsoever, a hospital’s
responsibility for the conduct of its *** medical
professionals.’ ” Jones, 191 Ill. 2d at 298, quoting Advincula,
176 Ill. 2d at 31.
To hold Dr. Parvathaneni liable, the jury would have had to
conclude that he deviated from the professional standard of care
to which a procuring surgeon is held. The standard of care for
Loyola as to the institutional negligence claim required a
showing of what a reasonably careful hospital would do under the
circumstances of this case. If, in fact, as the circuit judge
concluded, before institutional negligence can be found,
professional negligence on the part of Dr. Parvathaneni must be
found, the claims of professional negligence and institutional
negligence would conflate into a single theory of vicarious

39

No. 1-06-1536
liability. Dr. Parvathaneni’s commission of medical malpractice
would impose vicarious liability on Loyola, as principal to Dr.
Parvathaneni, and render the claim of institutional negligence
against Loyola pointless. The two claims, however, are
independent, as our supreme court has made clear. Because the
jury found in favor of Dr. Parvathaneni, it does not follow that
the jury was compelled to find in favor of Loyola on the
institutional negligence claim. See Collins v. Roseland
Community Hospital, 219 Ill. App. 3d 766, 775, 579 N.E.2d 1105
(1991) (verdicts not inconsistent because care provided at
hospital involved health professionals “requiring differing
degrees of care and subject to differing standards of care”).
Under the facts of this case no such outcome was required. The
jury was properly instructed that Loyola alone could be found
liable under the institutional negligence theory and the jury so
found.
The circuit judge, in concluding the verdict in favor Dr.
Parvathaneni and the verdict against Loyola could not stand, may
have been thinking of a case like Frigo, where the plaintiff
asserted a negligent credentialing claim in the context of
institutional negligence, involving a podiatrist, a nonemployee
of the hospital. Frigo, 377 Ill. App. 3d 43. If the plaintiff
successfully established a deviation of the standard of care of

40

No. 1-06-1536
the hospital resulting in wrongly extending credentials to the
podiatrist, then to establish proximate cause for the injury
inflicted on the plaintiff by the podiatrist on the independent
institutional claim, the plaintiff would also have to establish
that the podiatrist committed medical malpractice that gave rise
to the plaintiff’s injuries. Frigo, 377 Ill. App. 3d at 74-75.
If the podiatrist did not commit medical negligence, there would
be no causal connection between the hospital’s action in
negligently giving surgical privileges to the podiatrist and the
injuries the plaintiff suffered. Frigo, 377 Ill. App. 3d at 75.
Frigo, is much like Reynolds, the case upon which the
dissent so heavily relies. In each case, the plaintiff was
required to prove malpractice by the offending doctors. In
Frigo, the plaintiff had to prove the podiatrist committed
malpractice in order to succeed on her institutional negligence
claim against the hospital. In Reynolds, the plaintiffs were
required to prove not only that the surgeons “were negligent in
their diagnoses of these plaintiffs” but “that the hospitals
should have known, through proper review procedures, that the
surgeons were improperly diagnosing thoracic outlet syndrome.”
Reynolds, 168 Ill. App. 3d at 579.
Here, the plaintiff’s institutional claim was based on
Loyola’s deviation from the standard of care, not on any claimed

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No. 1-06-1536
deviation of the standard of care by Dr. Parvathaneni. In fact,
the jury found Dr. Parvathaneni did not commit medical
malpractice, a verdict supported by the evidence as the plaintiff
concedes. The focus of the plaintiff’s institutional negligence
claim against Loyola is entirely on Loyola’s training of Dr.
Parvathaneni, as the harvesting surgeon of the heart transplant
team. Even if “notice” under Reynolds were at the crux of the
plaintiff’s claim, it is disingenuous for Loyola to suggest that
it did not have “notice” that Dr. Parvathaneni was not trained to
evaluate the donor heart after harvesting when Loyola itself
trained Dr. Parvathaneni in his role as the harvesting surgeon of
the transplant team. It is no more plausible that Loyola had no
such notice than that Loyola was unaware heart transplants were
taking place in its hospital. As we have made clear, the instant
case is like neither Reynolds nor Frigo.
The dissent intimates that Aguilera v. Mount Sinai Hospital
Medical Center, 293 Ill. App. 3d 967, 691 N.E.2d 1 (1997),
provides guidance on proximate cause in this case.2 We find no

2 We find no legal significance to the dissent’s
observations that “there is no expert testimony of how long the
decedent could have lived; how long it would have taken to obtain
a new donor; or if the decedent was placed on a Jarvik-type
artificial heart, how long could the decedent live with the
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No. 1-06-1536
factual similarities between Aguilera and the case before us.
There is a life and death difference between a claim based on a
delay in ordering a CT scan that would have revealed a brain
hemorrhage that might or might not be operable and a claim that
Loyola removed a functioning heart (albeit, one that gave Mr.
Longnecker a 30% chance of surviving one year) and replaced it
with a nonfunctioning heart resulting in Mr. Longnecker’s death
four days later.
It was for the jury to determine whether there was
sufficient evidence of the breach of duty by Loyola and whether
there was a causal link between that breach and Mr. Longnecker’s
death. Based on the record evidence and the reasonable
inferences that may be drawn therefore, we cannot say “no

artificial heart.” (Slip op. at __.) Much like Dr. Foy’s
decision to remove Mr. Longnecker’s heart before discovering the
donor’s hypertrophic heart, the dissent’s unanswered questions
focus the analysis too late in the sequence of events. The
plaintiff’s claim is that Mr. Longnecker’s native heart should
never have been removed in the first instance when all Loyola had
to replace it with was a hypertrophic heart or other limited
measures that would not have returned Mr. Longnecker to the
position he was in before he was admitted to Loyola for a heart
transplant.

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No. 1-06-1536
contrary verdict based on that evidence could ever stand.”
Pedrick, 37 Ill. 2d at 510. Loyola was not entitled to judgment
n.o.v. on proximate cause.
II. Legally Inconsistent Verdicts
Dr. Parvathaneni contends the verdicts are not inconsistent
because different standards of care are involved in medical
negligence and institutional negligence. Collins, 219 Ill. App.
3d at 775, 579 N.E.2d 1105 (1991) (verdicts not inconsistent
because care provided at hospital involved health professionals
“requiring differing degrees of care and subject to differing
standards of care”). The plaintiff contends the verdicts are not
inconsistent because ” ‘the same element [was not] found to exist
and not to exist.’ ” Redmond v. Socha, 216 Ill. 2d 622, 649, 837
N.E.2d 883 (2005), quoting Black’s Law Dictionary 1592 (8th ed.
2004). Loyola contends “[t]he verdict in favor of Dr.
Parvathaneni broke any possible causal link between Loyola’s
conduct and Mr. Longnecker’s injuries.”
Loyola’s argument is in effect the reasoning of the circuit
judge that the verdicts were irreconcilable because the verdict
in favor of Dr. Parvathaneni precluded a showing of proximate
cause in the claim against Loyola, which we have already
rejected. Loyola presents no additional argument that we need
address on its claim of inconsistent verdicts.

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No. 1-06-1536
We also note that a holding of legally inconsistent
verdicts, under supreme court precedent, mandates that both
verdicts be vacated and a new trial ordered against Loyola and
Dr. Parvathaneni. Redmond, 216 Ill. 2d at 651 (“once a trial
court determines that jury verdicts are legally inconsistent,
whether to grant a new trial is not up to the trial court’s
discretion. It is mandatory”). The jury found the plaintiff
failed to prove her case against Dr. Parvathaneni. The plaintiff
does not contest this verdict but agrees with Dr. Parvathaneni’s
contention that “there was evidence from which the jury could
conclude that Parvathaneni was not negligent.” Vacating the
jury’s verdict in favor of Dr. Parvathaneni and remanding for a
new trial against him would be unjust in this case.
CONCLUSION
For the reasons stated above, the order of the circuit court
of Cook County is reversed and the matter is remanded for further
proceedings consistent with this opinion.
Reversed and remanded.
CAHILL, P.J., concurs.
R. GORDON, J., dissents.

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No. 1-06-1536

JUSTICE ROBERT E. GORDON, dis senting:

I respectfully dissent from the majority opinion where they find that plaintiff proved an

institutional negligence case against Loyola University Medical Center (Loyola). I believe the

trial judge’s decision should be affirmed; however, I agree that the verdicts were not inconsistent.

Illinoi s has long recogn ized that a hospi tal s may be held liab le for i ts own negligence. In

Darling v. Charleston Community Memorial Hospital, 33 Ill. 2d 326, 333 (1965), our Illinois

Supreme Court acknowledged an independent duty of hospitals to assume responsibility for the

care of their patients. “Ordinarily, this duty is administrative or managerial in character.” Jones

v. Chicago HMO Ltd., of Illinois, 191 Ill . 2d 278, 291 (2000 ), cit ing Advincula v. United Blood

Services, 176 Ill. 2d 1, 28 (1996). To fulfill its duty, a hospital must act as a “reasonably careful

hospital” would under similar circumstances. Advincula, 176 Ill. 2d at 29. Liability is

predicated on the hospital’s own negligence, not the negligence of the physician. Jones, 191 Ill.

2d at 284. This independent negligence of the hospital is known as institutional negligence or

direct corporate negligence.

In a medical negligence case, a plaintiff must prove by a preponderance of the evidence

that: (1) the defendant owed a duty of care; (2) the defendant breached that duty; and (3) the

plaintiff’s resulting injury or death was proximately caused by the breach. Hooper v. County of

Cook, 366 Ill. App. 3d 1, 6 (2006). I find no evidence in the record of this case of either a breach

of duty or causation. Plaintiff’s expert, Dr. Avery, testified that Loyola breached its duty because

“basically everybody needs to be on the same page in terms of what each team member’s role is

in the team.” Dr. Avery’s testimony concerning the “same page” was based on the fact that Drs.

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No. 1-06-1536

Foy and Mullen described the role of a procuring surgeon under the Loyola system differently

than Dr. Paravataneni did. Reynolds v. Mennonite Hospital, 168 Ill. App. 3d 575

(1988) is instructive as to whether the evidence in this case could support a verdict against

Loyola for its claimed failure to instruct Dr. Paravathaneni about his role on the heart transplant

team. In Reynolds, plaintiffs alleged that the hospital was institutionally negligent because it

failed to implement or follow standards of review to ensure the competency of its surgeons to

diagnose thoracic outlet syndrome. Reynolds, 168 Ill. App. 3d at 578-79. The appellate court

affirmed the trial court’s entry of summary judgment for the hospital because there was no

evidence that would have placed the hospital on notice of any malpractice by the surgeons.

Reynolds, 168 Ill. App. 3d at 580. In Reynolds, the plaintiff’s expert opined that the hospital

should have known, through proper review procedure, that its surgeons were improperly

diagnosing thoracic outlet syndrome; but the trial court concluded that the plaintiff’s expert’s

testimony was insufficient because there were no facts to substantiate that opinion. Reynolds,

168 Ill. App. 3d at 579-80. See also Rohe v. Shivde, 203 Ill. App. 3d 181, 202 (1990) (plaintiff

presented no evidence that the hospital failed to review the performance of the attending

pediatrician as to her compliance with hospital policy in examining newborn infants).

In the case at bar, there was no evidence that Loyola knew or should have known if Dr.

Paravathaneni had ever deviated from Loyola’s institutional policies or did not understand his

role on the heart transplant team. Plaintiff’s expert needed to identify what Loyola failed to do

that a “reasonably careful” hospital would have done under similar circumstances. Advincula,

176 Ill. 2d at 29.

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However, even if plaintiff was able to show the second element, namely a breach of the

standard of care, there was no evidence of the third element, namely, a causal relationship

between an alleged breach of duty and the death at issue. “ ‘[I]n order to sustain the burden of

proof, a plaintiff’s expert must demonstrate within a reasonable degree of medical certainty that

the defendant’s breach in the standard of care is more probably than not the cause of the injury.’ ”

Bergman v. Kelsey, 375 Ill. App. 3d 612, 625 (2007), quot ing Knauerhaze v. Nelson, 361 Ill.

App. 3d 538, 549 (2005).

Even if Dr. Paravathaneni had been properly advised of his role to evaluate the donor’s

heart for transplant purposes and advised Dr. Foy of his findings, there is no evidence that Dr.

Foy would not have used the donor’s heart. Plaintiff’s expert, Dr. Avery, testified that if Dr.

Paravathaneni had evaluated the donor heart after it was removed and before he made the “final

phone call” to Dr. Foy, he would have found what Dr. Foy later found: “a thick heart of

significant hypertrophy and considerable plaque in the coronaries.” Even though the donor heart

had more hypertrophy than Dr. Foy expected based on the echocardiogram, Dr. Foy knew this

and still decided that the heart was acceptable to transplant to the decedent. Dr. Foy rejected the

option of using an artificial heart instead.3 Dr. Foy made his decision based on the decedent’s

grave medical condition resulting from his failing heart.

The evidence in the record further indicates that after the heart was removed, Dr.

Paravathaneni found even more hypertrophy than he initially observed. The record contains no

3If Dr. Foy found that the donor’s heart was not suitable,
he testified he could have placed the decedent on a Jarvik-type
artificial heart.

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No. 1-06-1536

medical testimony concerning the effect of those observations or their medical significance for

causation.

After Dr. Paravathaneni removed the donor heart and made the telephone call to the

hospital , Dr . Foy removed the deceden t’s heart and p laced the deceden t on the hear t mach ine. If

the donor’s heart was not used, there is no expert testimony of how long the decedent could have

lived; how long it would have taken to obtain a new donor; or if the decedent was placed on a

Jarvik-type artificial heart, how long the decedent could have lived with the artificial heart.

This was a complex medical malpractice case that required a medical basis for the

expert’s opinion that Loyola’s breach of duty was a cause of the decedent’s death; and it is not

found in this record.

Dr. Avery’s test imony concerning causation was limited to the fol lowing:

“Q. Was Mr. Longnecker’s death caused as a result of the

deviat ions from the standard of care that we talked about today?

A. I believe they are.”

There was no basis for that opinion; and as a result, the element of causation was lacking. “An

expert’s opinion is only as valid as the basis and reasons for the opinion.” Wilson v. Bell Fuels,

Inc., 214 Ill. App . 3d 868, 875 (1991 ), cit ing McCormick v. Maplehurst Winter Sports, Ltd., 166

Ill. App. 3d 93, 100 (1988). “A party must lay a foundation sufficient to establish the reliability

of the bases for the expert’s opinion.” Petraski v. Thedos, No. 1-06-2914, slip op. at 11 (Ill.

App. C t. March 31, 2008) , citing Turner v. Williams, 326 Ill. App. 3d 541, 552-53 (2001).

In Aguilera v. Mount Sinai Hospital Medical Center, 293 Ill. App. 3d 967, 968 (1997),

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No. 1-06-1536

the plaintiff’s decedent was taken to the emergency room complaining of numbness on the right

side of his body. About six or seven hours later, a CT scan was taken, revealing a brain

hemorrhage. Aguilera, 293 Ill. App. 3d at 969. The patient died a few days later. Aguilera, 293

Ill. App. 3d at 969. Plaintiff presented two experts who testified that the emergency room

physician’s delay in taking the CT scan caused the decedent’s death. Aguilera, 293 Ill. App. 3d

at 969. It was the plaintiff’s theory that a diagnosis of the condition would have triggered

surgical intervention to prevent the decedent’s death. Aguilera, 293 Ill. App. 3d at 969-70.

However, on cross-examination, plaintiff’s experts admitted that they would defer to a

neurosurgeon as to whether surgery should have even been performed; yet the only

neurosurgeons testifying in the case stated that surgery would not have been appropriate.

Aguilera, 293 Ill. App. 3d at 969-70. This court held that the opinions offered by the plaintiff’s

experts lacked a sufficient factual basis and were therefore based on conjecture. Aguilera, 293

Ill. App. 3d at 975.

There just is not enough evidence in the record concerning breach of duty and causation

for this court to reverse the decision of the trial court. I would affirm.

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No. 1-06-1536

REPORTER OF DECISIONS – ILLINOIS APPELLATE COURT
_______________________________________________________________
CONNIE LONGNECKER, Individually and as Special Administrator
of the Estate of CARL LONGNECKER, Deceased,
Plaintiff-Appellant,

v.
LOYOLA UNIVERSITY MEDICAL CENTER, and
SIRISH PARVATHANENI, M.D.,
Defendants-Appellees.
_____________________________________________________________
No. 1-06-1536
Appellate Court of Illinois
First District, First Division
Filed: June 25, 2008
_________________________________________________________________
JUSTICE GARCIA delivered the opinion of the court.
CAHILL, P.J., concurs.
R. GORDON, J., dissents.
_________________________________________________________________
Appeal from the Circuit Court of Cook County
Honorable Irwin J. Solganick , Judge Presiding
_________________________________________________________________
Michael W. Rathsack
For PLAINTIFF –
APPELLANT
Tom Leahy
Peter D. Hoste
111 West Washington Street, Suite 962
Chicago, Illinois 60602

Krista R. Frick
For DEFENDANT –
APPELLEE,
John M. Stalmack
Sirish Parvathaneni, M.D. Bollinger, Ruberry & Garvey
500 West Madison, Suite 2300
Chicago, Illinois 60661

For DEFENDANT –
APPELLEE,
Loyola University
Medical Center

Thomas J. Burke, Jr.
Ben Patterson
Hall Prangle & Schoonveld, LLC
200 South Wacker Drive, Suite 3300
Chicago, Illinois 60606

Eugene A. Schoon
Sherry A. Knutson
51

No. 1-06-1536

Sidley Austin, LLP
One South Dearborn Street
Chicago, Illinois 60603

52

Lourdes Med. Pavilion v. Cath. Healthcare Partners, Inc

Lourdes Med. Pavilion v. Cath. Healthcare Partners, Inc

UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF KENTUCKY
PADUCAH DIVISION

CIVIL ACTION NO. 5:03CV-231-M

LOURDES MEDICAL PAVILION, LLC PLAINTIFF

v.

CATHOLIC HEALTHCARE PARTNERS, INC.

DEFENDANT

MEMORANDUM OPINION AND ORDER

This matter is before the Court on a motion by Defendant, Catholic Healthcare

Partners, Inc., for summary judgment [DN 18]. The Plaintiff, Lourdes Medical Pavilion,

LLC, responded [DN 21] and the Defendant replied [DN 22]. On January 31, 2006, this

matter was transferred to the undersigned. By Order entered February 3, 2006, the Court

requested the parties file additional briefs addressing the applicability of KRS § 275.340.

The parties have filed the requested briefs and responses [DN 28, DN 29, DN 30, DN 31].

Fully briefed, this matter is ripe for decision. For the reasons set forth below, CHP’s Motion

for Summary Judgment is DENIED.

I. FACTS

On May 29, 1998, Lourdes Hospital, Inc. (hereinafter “Lourdes”) and the PAPI

corporate entities1 (hereinafter “PAPI”) formed Lourdes Medical Pavilion, LLC, (hereinafter

“LMP”) with each entity owning fifty percent of the limited liability company. Lourdes is

1The PAPI entities include: Paducah Area Physicians Incorporated; SurgiCare; Paducah
Medical Center Realty; and Health Care Management Resources, Inc.

a nonstock, nonprofit corporation. Catholic Healthcare Partners, Inc. (hereinafter “CHP) is

the sole member of Lourdes. Lourdes and PAPI entered into an Operating Agreement

governing the control and management of LMP. LMP provides diagnostic services,

ambulatory surgery services, and other healthcare services to patients residing in Paducah,

Kentucky and surrounding areas. LMP also operates a medical office building which is

used primarily by members of the medical staff of Lourdes Hospital. Under the Amended

and Restated Operating Agreement of LMP, Lourdes and PAPI agreed not to engage in

owning and operating a multi-purpose medical office building in competition with LMP.

They further agreed not to expand any outpatient surgery centers or otherwise compete with

LMP in the provision of outpatient surgery services. (January 1, 2000 LMP’s Amended and

Restated Operating Agreement at Section 3.7 and Annex E.)

In December of 1998, LMP and CHP entered into a Non-Competition Agreement

under which CHP agreed that it or any affiliate would not engage in “acquiring, starting up,

and owning, operating, disposing of, and otherwise dealing with any of the lines of business

carried on by [LMP]” including owning or operating a multi-purpose medical office building

and expanding Lourdes Outpatient Surgery Center. (LMP/CHP Non-Competition

Agreement at § 1 (a),(b)(citing Annex. E to the Lourdes/PAPI Operating Agreement.)) An

“affiliate” for purposes of the Non-Competition Agreement “means any entity of which CHP

has a greater than 50% interest in the entity’s control or equity.” (Non-Competition

Agreement §1(f).) According to the terms of the Non-Competition Agreement, in the event

of a breach by CHP, LMP “shall be entitled to obtain a temporary restraining order and

2

temporary and permanent injunctive relief . . . [and] the recovery of damages . . .” (Non-

Competition Agreement §5.)

In 2002, CHP announced plans to construct a new $27 million Marshall Nemer

Pavilion, which would contain new medical offices and have more space for outpatient

surgery. CHP did not give PAPI or LMP any notice of these plans, and by April of 2002

PAPI believed that the new project announced by CHP violated the terms of the Non-

Competition Agreement between LMP and CHP. At a LMP Board of Directors meeting on

April 25, 2002, Dr. Robert Meriwether, on behalf of PAPI, moved for LMP to employ legal

counsel to look into the actions of CHP and file legal action against CHP. The motion did

not pass. A subsequent motion made at the next Board of Directors meeting on August 15,

2002 failed as well.

On September 30, 2003, LMP filed this complaint against CHP alleging multiple

breach of contract claims, tortious interference, breach of fiduciary duties, and breach of the

covenant of good faith and fair dealing. Specifically, LMP alleges that CHP breached the

Non-Competition Agreement by expanding outpatient surgery services and construction of

new physician office space. CHP filed this current motion for summary judgment arguing

that LMP lacked the corporate authority to bring suit against CHP and, as a result, the claims

against CHP should be dismissed.

II. STANDARD OF REVIEW

In order to grant a motion for summary judgment, the Court must find that the

pleadings, together with the depositions, interrogatories and affidavits, establish that there

3

is no genuine issue of material fact and that the moving party is entitled to judgment as a

matter of law. Fed. R. Civ. P. 56. The moving party bears the initial burden of specifying the

basis for its motion and of identifying that portion of the record which demonstrates the

absence of a genuine issue of material fact. Celotex Corp. v. Catrett, 477 U.S. 317, 322

(1986). Once the moving party satisfies this burden, the non-moving party thereafter must

produce specific facts demonstrating a genuine issue of fact for trial. Anderson v. Liberty

Lobby, Inc., 477 U.S. 242, 247-48 (1986). The inquiry under Fed. R. Civ. P. 56(c) is

“whether the evidence presents a sufficient disagreement to require submission to a jury or

whether it is so one-sided that one party must prevail as a matter of law.” Id. at 251-52

(1986). See also Street v. J.C. Bradford & Co., 886 F.2d 1472, 1479 (6th Cir. 1989).

III. DISCUSSION

Defendant, CHP, argues that LMP lacked the corporate authority to bring suit against

CHP because a majority of the Board of Directors of LMP never approved this action as

required under the terms of the LMP Operating Agreement, and as a result, summary

judgment in favor of CHP is warranted. LMP disagrees and maintains that the authority to

bring this suit comes from Section 15.9 of the LMP Operating Agreement and KRS

§275.335.

A. The LMP Operating Agreement

Under the terms of the Operating Agreement, LMP is managed by an elected Board

of Directors, five of whom are from Lourdes and five of whom are from PAPI. (Operating

Agreement at § 9.1.) The Board of Directors have the authority to delegate certain action to

4

an Executive Committee consisting of two individuals, one appointed by the Lourdes

Directors and one appointed by the PAPI Directors. (Operating Agreement at § 9.3.)

Pursuant to Section 9.4 of the Operating Agreement, “[a]ny act to be taken by the Directors

shall be subject to approval by the majority vote of the Directors.” The Operating Agreement

further provides that “[i]n all such instances, the Lourdes Directors shall have one collective

vote and the PAPI Directors shall have one collective vote.” (Operating Agreement at § 9.4.)

In the event the Directors fail to reach an agreement on matters that come before them,

the Operating Agreement provides that “the Members or the Directors . . . agree to abide by,

and to cause the Company to abide by, the dispute resolution mechanism” set forth in Article

14 of the Operating Agreement. (Operating Agreement Section 14.1.) Further, Section 15.9

of the Operating Agreement entitled “Enforcement,” states in relevant part:

In the event of a breach or threatened breach by a Member or Manager of any
of the provisions of this Agreement, the Company shall be entitled to obtain
a temporary restraining order and temporary and permanent injunctive relief
. . . . Nothing in this Agreement may be construed as prohibiting the Company
from pursuing any other remedy or remedies, including without limitation, the
recovery of damages. . . . Notwithstanding anything to the contrary herein, the
determination of whether the Company shall pursue actions for breach of this
Agreement by a Member shall be made exclusively by (i) Lourdes, if the
alleged breach is by a PAPI Entity, or (ii) the PAPI Entities, if the alleged
breach is by Lourdes.

(Operating Agreement § 15.9.)

B. LMP’s Authority to Sue under Section 9.4 of Operating Agreement

CHP contends that LMP did not have the corporate authority to sue pursuant to

section 9.4 of the Operating Agreement. Section 9.4 provides that “any act” taken by the

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Board of Directors must be approved by a majority vote. Therefore, under this section, in

order for LMP to bring suit against CHP for the alleged breach of the Non-Competition

Agreement, both the Lourdes Entity and the PAPI Entities had to approve the lawsuit.

(Operating Agreement at § 9.4.) Because Lourdes refused to authorize suit, LMP was not

authorized under the Operating Agreement to file suit. As discussed above, the Operating

Agreement provides that in the event the Members fail to reach an agreement on matters that

come before them, Lourdes and PAPI agree to abide by the dispute resolution mechanism set

forth in Article 14 of the Operating Agreement. (Operating Agreement § 14.1.) Therefore,

under the terms of the Operating Agreement, PAPI and Lourdes were required to participate

in dispute resolution to resolve the issue of whether LMP could file suit against CHP for

breach of the Non-Competition Agreement. Clearly, given the terms of the LMP Operating

Agreement, LMP did not have the corporate authority to sue CHP.

C. LMP’s Authority to Sue under Section 15.9 of the Operating Agreement

LMP maintains that it did not need the majority of the Directors’ votes pursuant to

section 9.4 of the Operating Agreement because Section 15.9 of the Operating Agreement

specifically authorizes an action by LMP against a member in breach of the Operating

Agreement.

Contrary to LMP’s assertion, this action is not an action by one member of the limited

liability company against another member pursuant to Section 15.9 to enforce the terms of

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the Operating Agreement.2 While the Court recognizes that CHP is the sole member of

Lourdes, there is no indication in the record at this time that CHP and Lourdes are the same

corporate entity. Both parties recognize that Lourdes Hospital is a Kentucky nonstock,

nonprofit corporation and CHP is an Ohio nonprofit corporation. In fact, until this action at

least, it appears that the parties treated CHP and Lourdes as separate, distinct entities. For

instance, in May of 1998, Lourdes and PAPI entered into an Operating Agreement that

governed the management of the limited liability company, LMP. The Operating Agreement

contained a non-competition clause that governed the activity of both Lourdes and PAPI with

respect to LMP. In December of 1998, LMP and CHP then entered into a Non-Competition

Agreement to govern “CHP’s obligations concerning activities that may compete with the

LLC.” (Non-Competition Agreement at p. 1.) If CHP and Lourdes were the same entity then

why would the parties feel it necessary to enter into another non-competition agreement

addressing the same business activities contained in the Operating Agreement between

Lourdes and PAPI.

While the complaint references Lourdes and Lourdes’s conduct, LMP has sued only

CHP. LMP could have properly sued Lourdes for a breach of the Operating Agreement

pursuant to Section 15.9. As discussed above, Section 15.9 provides that “the determination

of whether the Company shall pursue actions for breach of this Agreement by a Member

shall be made exclusively by . . . the PAPI Entities, if the alleged breach is by Lourdes.”

2Interestingly, at times even Defendant refers interchangeably to CHP and Lourdes.

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Instead, LMP chose to bring this action solely against CHP for breach of contract and

tortious interference relating to the Non-Competition Agreement between LMP and CHP.

Therefore, Section 15.9 of the LMP Operating Agreement does not authorize LMP’s suit

against CHP.

C. Kentucky Limited Liability Company Act

LMP maintains that authority to bring the present action also comes from KRS §

275.335 of the Kentucky Limited Liability Company Act which allows one member of a

limited liability company (hereinafter “LLC”) to bring suit on behalf of the LLC despite the

majority vote requirement if a member has an interest in the vote and/or outcome of the

litigation that would be adverse to the LLC. KRS §275.335 provides:

Unless otherwise provided in a written operating agreement, a suit on behalf
of the limited liability company may be brought in the name of the limited
liability company only by:

(1) One (1) or more members of a limited liability company, whether or not
the operating agreement vests management of the limited liability
company in one (1) or more managers, who are authorized to sue by the
vote of more than one half (½) of the number of members eligible to
vote thereon, unless the vote of all members shall be required pursuant
to KRS 275.175(1). In determining the vote required under KRS
275.175, the vote of any member who has an interest in the outcome of
the suit that is adverse to the interest of the limited liability company
shall be excluded; or

(2) One (1) or more managers of the limited liability company, if an
operating agreement vests management of the limited liability company
in one (1) or more managers, who are authorized to do so by the vote
required pursuant to KRS 275.175 of the managers eligible to vote
thereon. In determining the required vote, the vote of any manager who
has an interest in the outcome of the suit that is adverse to the interest
of the limited liability company shall be excluded.

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KRS § 275.335.

CHP contends that KRS § 275.335 does not permit LMP to sue because the terms of

the LMP Operating Agreement controls. The Court agrees. Clearly, the phrase “[u]nless

otherwise provided in a written operating agreement” contained in KRS § 275.335 includes

Section 9.4 of the LMP Operating Agreement, which provides that “any act” taken by the

Board of Directors must be approved by a majority vote. Therefore, despite the remainder

of KRS § 275.335 cited by LMP, in order for LMP to bring suit against CHP for the alleged

breach of the Non-Competition Agreement, both the Lourdes Entity and the PAPI Entities

had to approve the lawsuit. (Operating Agreement at § 9.4.) As noted above, because

Lourdes refused to authorize suit, LMP was not authorized under the Operating Agreement

to file suit.

Notwithstanding, this finding does not resolve the question of whether summary

judgment is appropriate under Kentucky law. KRS § 275.340 of the Kentucky Limited

Liability Company Act prohibits the use of “authority to sue” as a defense in an action

brought on behalf of the LLC. Specifically, KRS § 275.340, entitled “Effect of

determination that member or manager lacks authority to sue on behalf of company,”

provides:

A determination that a member or manager does not have authority to sue on
behalf of the limited liability company shall not be asserted as a defense to an
action brought by the limited liability company or as a basis for the limited
liability company to bring a subsequent suit on the same cause of action.

KRS § 275.340.

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CHP maintains that while KRS § 275.340 by its terms may not allow it to assert as a

defense that a member or manager did not have authority to bring suit, this statute should not

be allowed to contravene or negate other parts of the Kentucky Limited Liability Company

Act. Specifically, CHP argues that KRS § 275.335 specifically provides that the LMP

Operating Agreement controls and the Operating Agreement requires a majority vote of the

Directors in order to bring suit on behalf of LMP.

The Court rejects CHP’s argument. The language of KRS § 275.340 clearly and

unambiguously provides that the “lack of authority of a member or manager to file suit on

behalf of an LLC may not be used as a defense to an action filed by the LLC.” Thomas

Rutledge and Lady Booth, The Limited Liability Company Act: Understanding Kentucky’s

New Organizational Option, 83 Ky. L.J. 1, 42 (1995). Accordingly, even though the Court

has determined this suit was not authorized by the Board of Directors of LMP, CHP cannot

use this as a defense pursuant to the clear language of KRS § 275.340. For these reasons, the

Court finds summary judgment against LMP is not warranted.

IV. CONCLUSION

For the reasons set forth above, IT IS HEREBY ORDERED that the motion by

Defendant, CHP, for summary judgment [DN 18] is DENIED.

cc: counsel of record

10

Longnecker v. Loyola Univ. Med. Ctr.

Longnecker v. Loyola Univ. Med. Ctr.

NEGLIGENCE – HOSPITAL AND PHYSICIAN

Longnecker v. Loyola Univ. Med. Ctr., No. 1-06-1536 (Ill. App. Ct. June 25, 2008)

A jury found that a heart surgeon who harvested a heart that was alleged to be hypertrophic, and thus inappropriate for transplant, was not negligent. However, the jury then found that the hospital at which the transplant occurred was liable for "institutional negligence." The trial court found that these verdicts were irreconcilable and issued a JNOV. The Appellate Court of Illinois reversed the trial court’s JNOV. The appellate court reasoned that such an outcome was not necessarily inconsistent because a hospital can be liable for institutional negligence irrespective of the physician’s negligence. The appellate court then ordered a new trial on the issue of the hospital’s negligence.