Smith v. Richmond Memorial Hosp.

• Decision Date: 17 April 1992
• Docket Number: No. 910585,910585
• Citation: 416 S.E.2d 689,243 Va. 445
• Court: Virginia Supreme Court
• Parties: , 60 USLW 2675, 37 Soc.Sec.Rep.Ser. 223, Medicare & Medicaid Guide P 40,168 Taja SMITH, an Infant, etc., et al. v. RICHMOND MEMORIAL HOSPITAL. Record

Page 689

416 S.E.2d 689

243 Va. 445, 60 USLW 2675, 37 Soc.Sec.Rep.Ser. 223,

Medicare & Medicaid Guide P 40,168

Taja SMITH, an Infant, etc., et al. v. RICHMOND MEMORIAL HOSPITAL.

Record No. 910585.

Supreme Court of Virginia.

April 17, 1992.

Edward W. Taylor (Taylor & Schockemoehl, on briefs), Richmond, for appellants.

Judith B. Henry (Crews & Hancock, on brief), Richmond, for appellee.

Present: CARRICO, C.J., COMPTON, STEPHENSON, WHITING, LACY and KEENAN, JJ., and COCHRAN, Retired Justice.

LACY, Justice.

In this case we consider whether the trial court properly sustained a demurrer without leave to amend on the ground that the motion for judgment failed to state a cause of action under the Emergency Medical Treatment and Women in Active Labor provisions of the Consolidated Omnibus Budget Reconciliation Act (COBRA or the Act), 42 U.S.C. § 1395dd (1988).

The circumstances of this case involve the medical treatment of a pregnant woman who subsequently gave birth to a child. We recite the facts as set out in the pleadings, taken as true for the purposes of reviewing the trial court's action on the demurrer. Bowman v. State Bank of Keysville, 229 Va. 534, 536, 331 S.E.2d 797, 798 (1985).

Connie Elizabeth Smith was admitted to Richmond Memorial Hospital (the Hospital) as a patient on July 18, 1988. Ms. Smith was approximately 33 weeks pregnant and had premature rupture of the uterine membranes. Ms. Smith remained at the Hospital until July 23, 1988.

During the afternoon of July 22, 1988, Ms. Smith complained of abdominal cramping and vaginal leakage. The discharge had turned to a greenish yellow color. In the afternoon and again at 10:00 p.m. she was given Nembutal, a hypnotic drug. By 10:00 p.m., Ms. Smith was complaining of irregular abdominal pain and contractions. By 10:30 p.m., her contractions were timed at five minute intervals. At 11:45 p.m., she was taken to the labor and delivery facilities of the Hospital. The vaginal discharge was now dark green in color. By midnight, the opening to the patient's uterus had dilated one centimeter, she had cold chills, and her temperature had dropped to 95.3 degrees Fahrenheit.

At 1:00 a.m., the Hospital called a physician, who ordered that Ms. Smith be transferred to the Medical College of Virginia Hospital (MCV). The physician was not Ms. Smith's regular attending physician, and he gave the verbal transfer order without examining her. Following the transfer order, a nurse began trying to locate an ambulance service to transfer Ms. Smith to MCV. Two services refused, and one was not obtained until the Richmond Memorial administrator agreed that the cost of the transfer could be billed to MCV. Connie Smith was taken from the Hospital at 2:10 a.m. and was admitted to MCV at approximately 2:30 a.m. on July 23, 1988.

A medical resident at MCV assessed Ms. Smith's condition to be "(1) prolonged premature rupture of the membranes, (2) pre-term labor at 34 weeks, (3) the Chorioamnionitis should be ruled out, and (4) that there was questionable meconium discharge." At 3:00 a.m., Ms. Smith signed a consent for a caesarean delivery, if necessary. Her contractions were one to five minutes apart at 4:20 a.m. She was taken "emergently" to the delivery room where the child, Taja Smith, was delivered by caesarean operation at approximately 9:48 a.m. Both mother and child suffered substantial injuries. Taja has cerebral palsy and is severely brain damaged.

Ms. Smith sued Richmond Memorial Hospital in her individual capacity and on behalf of her daughter Taja (collectively Smith), claiming a violation of COBRA and seeking damages. The Hospital demurred on three grounds: (1) the claims are "actually those alleging medical malpractice" and, therefore, the circumstances alleged cannot support a claim against the Hospital under COBRA; (2) no actionable claim under COBRA was stated because Smith did not allege that indigency was the motivating reason for the transfer from Richmond Memorial Hospital to MCV; and (3) no notice of claim as required by Code § 8.01-581.2 was given.

The trial court first determined that Code § 8.01-581.2 notice of claim provisions were inapplicable to claims based on a COBRA violation. Next, stating that the "crux of the issue presented by plaintiff is that she remained at Richmond Memorial without adequate care," the trial court held that COBRA does not cover "emergency conditions arising from medical neglect during a stay in a hospital." Accordingly, the trial court agreed with the Hospital's argument that Smith's claim was actually one for medical malpractice and held that a cause of action under COBRA was not sufficiently plead. The trial court sustained the demurrer without leave to amend.

We awarded Smith an appeal. We also granted a review of the Hospital's assignment of cross-error regarding the applicability of the notice of claim provisions of Code § 8.01-581.2 to claims filed under COBRA. ¹

I.

Congress enacted COBRA in 1986 in response to the growing number of instances in which hospitals were refusing to treat individuals with emergency medical conditions, a practice generally referred to as "patient dumping." Under the common law, private hospitals have no duty to accept or to provide treatment for patients. While private hospitals traditionally did treat people in emergency situations, they generally were not fully compensated, or were not compensated at all, for treatment of indigent patients. With growing competition among hospitals, shifting this cost to paying patients became more difficult. As the hospitals' economic losses increased, the instances of patient dumping also increased. To counteract patient dumping and the resultant hardship and injury, COBRA established specific standards for the evaluation, treatment, and transfer of patients. Abercrombie v. Osteopathic Hosp. Founders Ass'n, 950 F.2d 676, 680 (10th Cir.1991); Gatewood v. Washington Healthcare Corp., 933 F.2d 1037, 1039 (D.C.Cir.1991); Cleland v. Bronson Health Care Group, Inc., 917 F.2d 266, 268 (6th Cir.1990); Andrew Jay McClurg, Your Money or Your Life: Interpreting the Federal Act Against Patient Dumping, 24 Wake Forest L.Rev. 173, 197-99 (1989); Karen I. Treiger, Note, Preventing Patient Dumping: Sharpening the Cobra's Fangs, 61 N.Y.U.L.Rev. 1186, 1187-88 (1986).

II.

The Hospital argues that Smith did not plead a claim under COBRA for two reasons. First, asserting that coming to an emergency room in an emergency medical condition or in active labor is a prerequisite to the application of the treatment and transfer provisions of subsections (b) and (c) of the Act, the Hospital argues that Smith's claim fails because she did not plead that she came to the emergency room in such a condition. Furthermore, the Hospital asserts that Smith's admission that her condition had been stabilized prior to the events giving rise to her transfer to MCV absolves the Hospital from liability under COBRA. Second, the Hospital argues that Smith's claim is one for misdiagnosis or improper treatment, and, therefore, that it is not cognizable under COBRA. In response, Smith contends that, under the Act's language, a patient need not be transferred from an emergency room to establish a COBRA cause of action, and that a hospital cannot escape COBRA liability by "initially stabilizing a patient, allowing the patient to again become unstable, and then transferring the patient."

Although framed in terms of the sufficiency of the pleading, the crux of the issue in this case is one of statutory interpretation: (1) whether COBRA's treatment and transfer requirements are limited solely to an emergency medical condition or active labor which has not been stabilized and which occurs in conjunction with initial admission to an emergency department; or (2) whether those requirements also apply when an emergency medical condition or active labor commences after the admission and initial stabilization of the patient's condition.

To resolve the parties' conflicting interpretations, we begin with an examination of the Act itself. At the time of the alleged violation, 42 U.S.C. § 1395dd stated in relevant part:

(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 ... for examination or treatment ... the hospital must provide for an appropriate medical screening examination ... to determine whether or not an emergency medical condition ... exists or to determine if the individual is in active labor....

(b) Necessary stabilizing treatment for emergency medical conditions and active 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 or is in active labor, the hospital must provide either--

(A) ... such further medical examination and such treatment as may be required to stabilize the medical condition or ... provide for treatment of the labor, or

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

. . . . .

(c) Restricting transfers until patient stabilized

(1) Rule

If a patient at a hospital has an emergency medical condition which has not been stabilized ... or is in active labor, the hospital may not transfer the patient unless--

(A)(i) the patient ... requests that the transfer be effected, or

(ii) a physician ... or other qualified medical personnel when a physician is not readily available in the emergency department, has signed a certification that ... the medical benefits reasonably expected from the ... [transfer] outweigh the increased risks to the individual's medical condition from effectuating the transfer....

(Emphasis added.)

The language used in each subsection describes...