Rodriguez v. American Intern. Ins. Co. of P. Rico

Decision Date12 May 2003
Docket NumberNo. CIV. 02-1810(JP).,CIV. 02-1810(JP).
Citation263 F.Supp.2d 297
PartiesJoan RODRIGUEZ, et al., Plaintiffs, v. AMERICAN INTERNATIONAL ISURANCE COMPANY OF PUERTO RICO, et al., Defendants
CourtU.S. District Court — District of Puerto Rico

Ramon L. Walker-Merino, Esq., San Juan, PR, for Plaintiff.

Luis R. Ortiz Segura, Esq., Karla S. Mellado Delgado, Esq., Pinto-Lugo, Oliveras & Ortiz, PS, Ivette Berrios, Esq., San Juan, PR, for Defendants.

OPINION AND ORDER

PIERAS, Senior District Judge.

I. INTRODUCTION AND PROCDURAL BACKGROUND

Before the Court is the issue of whether the Emergency Medical Treatment and Active Labor Act ("EMTALA") applies to Puerto Rico's "Centros de Diagnostico y Tratamiento" (hereinafter "CDTs"), an issue of first impression before this Court. Plaintiffs in this case are Joan Rodriguez, Domingo Diaz Rojas, and their conjugal partnership. On March 3, 2001, Plaintiffs' four month old daughter, Lilliam Diaz Rodriguez, was rushed to the Corozal CDT after she vomited in church. She arrived at the same in respiratory distress on or about 9:00 p.m. Plaintiffs aver that the initial evaluation performed on the child was inadequate and failed to comply with EMTALA requirements for an appropriate medical screening. They further assert that it was this faulty screening that failed to detect the emergency condition of the child in order to properly stabilize and transfer her, as a result of which she died. They brought this cause of action alleging violations of EMTALA and Puerto Rico law.

Defendants are Corporation de Servicios Integrados de Salud de Area de Barranquitas, Corozal, Naranjito y Orocovis, who owns the Corozal CDT; its insurer, American International Insurance Company of Puerto Rico; and Aeromed Services. On January 17, 2003, the Corozal CDT filed a motion requesting summary judgment on the grounds that it is not an emergency room or a hospital within the meaning of EMTALA and that consequently, no cause of action under said statute can ensue against it. After thoroughly and carefully analyzing the issue, the Court concludes that the provisions of EMTALA apply to CDTs in Puerto Rico that offer twentyfour hour emergency room services, and that consequently, Plaintiffs have a colorable claim under said statute.

II. THE LAW

The Emergency Medical Treatment and Active Labor Act, better known by its acronym, "EMTALA," imposes statutory duties of physicians that treat patients in emergency rooms. EMTALA was enacted by Congress in 1996, in the face of "the increasing number of reports that hospital emergency rooms are refusing to accept or treat patients with emergency conditions if the patient does not have medical insurance." H.R.Rep. No. 241(1), 99th Cong., 1st Sess. 27 (1986). "The intent of this bill is honorable, that is to address concerns about inadequate health care for our citizens who do not have health insurance or who are `underinsured'". 1986 U.S.C.C.A.N. 3, 460 (1986) (additional views of Senator Orrin Hatch).

"Many are quick to say the problem lies with the health care providers— hospitals and physicians who are anxious to reap ever-increasing profits and who seem unconcerned with public health and well-being. There have been disturbing reports about hospitals referring, and in some instances refusing to treat patients who present themselves for care, but who don't have health insurance. Others apparently require a substantial cash deposit from uninsured patients before admitting the individual for care. This has been referred to as taking a `wallet biopsy' before determining if the individual merits treatment. When this occurs to individuals in need of medical care it is unconscionable and completely contrary to the proud tradition of our health care professionals." Id. at 461.

In addition, the main focus of this bill was not only to ensure that every person who needed medical care received it, but that the medical care was offered in a speedy and efficient manner. "Regional trauma centers are specifically designed to direct patients to a number of different medical facilities so that patients may receive the best possible medical care as quickly as possible." Id. at 465 (submission by the Law Firm of Kenny Nachwalter & Seymour to the Honorable Peter W. Rodino, Jr., Chairman, Committee on the Judiciary, September 4, 1985); "The Committee is most concerned that medically unstable patients are not being treated appropriately. There have been reports of situations where treatment was simply not provided". H.R.Rep. No. 99-241(1), 1986 U.S.C.C.A.N. 579, 604 (1985).

The text of the statute, codified at 42 U.S.C. § 1395dd, reads as follows:

§ 1395dd. Examination and treatment for emergency medical conditions and women in labor

(a) Medical screening requirement In the case of a hospital that has a hospital emergency department, if any individual (whether or not eligible for benefits under this subchapter) comes to the emergency department and a request is made on the individual's behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (within the meaning of subsection (e)(1) of this section) exists.

(b) Necessary stabilizing treatment for emergency medical conditions and labor

(1) In general If any individual (whether or not eligible for benefits under this subchapter) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either—

(A) within the staff and facilities available at the hospital, for such further medical examination and such treatment as may be required to stabilize the medical condition, or

(B) for transfer of the individual to another medical facility in accordance with subsection (c) of this section.

42 U.S.C. § 1395dd

More recently, the statute was amended to include other health care providers such as hospitals located in rural areas and off campus hospital outpatient departments. See 42 U.S.C. § 1395cc; 42 C.F.R. § 413.65.

III. ANALYSIS

In Puerto Rico, unique health facilities known as CDTs exist. Under Puerto Rico Law, a CDT is defined as: an independent facility or one operated in conjunction with a hospital which provides community services for the diagnosis and treatment of ambulatory patients under the professional supervision of persons licensed to practice medicine, surgery or dentistry in Puerto Rico. 24 P.R. Laws Ann. § 331a(4). In other words, these are limited health facilities that offer only outpatient services such as dentistry, X-ray, and laboratory services. Defendant provides the following services at its CDT: Family medicine; general medicine; pediatrics; internal medicine; gynecology; dentistry; emergency room services; pharmacy; laboratory; X-ray services; sonograms and electrocardiograms. As of this writing, there are approximately 192 CDTs in Puerto Rico. See 2002 Directory of Health Facilities, Statistics Division, published by the Puerto Rico Department of Health.

Because CDTs in Puerto Rico are the "first line of defense", as it were, in many rural communities, the Court must evaluate this situation carefully, keeping in mind the important public policy concerns inherent in this case. For most rural residents, their local CDT is the place where they receive the majority of their medical treatment. CDTs are rather unique in the sense that they do not offer inpatient hospital services, but do offer other services that a hospital by itself might not be able to offer, like dentistry services.

"The `Centros de Diagnostico y Tratamiento' and the `Centros de Salud' form the primary level of the health system in Puerto Rico. They are deemed primary not only because it is the beginning point, or the point of entry, into the system, but also because it is the first and principal health custodian, both individually as well as community-wise. It is well recognized and accepted that the efficiency of a health system and the quality of its services are determined in accordance with the level of community health, and by the success in disease prevention. This great responsibility falls primarily at the primary level."

Legislative History, Law 52 of July 2, 1985 (Court translation).

Therefore, it is clear to the Court the importance of the CDTs, many of which operate as the only health facility in rural vicinities.

It has been well established, and Defendant correctly points out, that EMTALA only applies to participating hospitals who have executed a Medicare provider agreement with the federal government. See Hardy v. New York City Health & Hosp. Corp. 164 F.3d 789 (2d Cir.1999); Cherukuri v. Shalala, 175 F.3d 446, (6th Cir.1999); Summers v. Baptist Medical Ctr. Arkadelphia, 91 F.3d 1132 (8th Cir. 1996); Jackson v. East Bay Hosp., 246 F.3d 1248, 1260 (9th Cir.2001); Eberhardt v. City of Los Angeles, 62 F.3d 1253 (9th Cir.1995); Torres Otero v. Hospital General Menonita, 115 F.Supp.2d 253 (D.Puerto Rico 2000) (Pieras, J). In addition, it has been clearly established that the person seeking treatment must come to the emergency room in order for EMTALA apply. See Lopez-Soto v. Hawayek, 175 F.3d 170 (1st Cir.1999); St. Anthony Hosp. v. U.S. Dept. of Health and Human Servs., 309 F.3d 680 (10th Cir.2002).

Defendant alleges that it is not a hospital within the meaning of the statute. Under normal circumstances, the Court would agree that a clinic, which is really what a CDT is more akin to, does not fall under the auspices of EMTALA. See Roberts v. Virginia, U.S. Brief, 1998 WL 649036 (1998) (EMTALA does not apply to physician's offices, clinics, nursing homes, hospices or departments of hospitals other than the emergency room) (citing Baber v. Hospital Corp. of America, 977 F.2d 872, 884 (4th Cir.1992))....

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