Stafford v. Neurological Medicine, Inc.

• Decision Date: 27 March 1987
• Docket Number: No. 86-1352,86-1352
• Citation: 811 F.2d 470
• Parties: Robert STAFFORD, Appellant, v. NEUROLOGICAL MEDICINE, INC. and Raymond F. Cohen, D.O., Appellees.
• Court: U.S. Court of Appeals — Eighth Circuit

Page 470

811 F.2d 470

Robert STAFFORD, Appellant, v. NEUROLOGICAL MEDICINE, INC. and Raymond F. Cohen, D.O., Appellees.

No. 86-1352.

United States Court of Appeals Eighth Circuit.

Submitted Nov. 13, 1986.

Decided Feb. 11, 1987.

Rehearing Denied March 27, 1987.

Alvin A. Wolff, Jr., St. Louis, Mo., for appellant.

David I. Hares, St. Charles, Mo., for appellees.

Before JOHN R. GIBSON, FAGG and MAGILL, Circuit Judges.

JOHN R. GIBSON, Circuit Judge.

Robert Stafford brought this negligence action against Neurological Medicine, Inc. (NMI), and Dr. Raymond F. Cohen based on an insurance form signed by Dr. Cohen which incorrectly stated that Stafford's wife, Pauline, was "diagnosed" as having a brain tumor. Two days after reading this form, Pauline committed suicide. A jury returned a verdict for $200,000. The district court, however, granted both defendants' motions for judgment notwithstanding the verdict, reasoning that the evidence failed to create a submissible jury question on the element of causation. It also conditionally granted a new trial for both defendants, stating that "as to both liability and damages the jury's verdict in this cause was against the great weight of the evidence." Stafford v. Neurological Medicine, Inc., No. 85-486C(C) (E.D.Mo. Mar. 5, 1986). We reverse and remand for entry of judgment on the jury's verdict.

I.

On the morning of January 14, 1985, Robert Stafford went out to chop wood on the eighty acres surrounding the farm home where he and his wife Pauline had lived since their marriage in 1952. Pauline stayed inside. She typed her husband's business agenda, as she always did, for his Tuesday night meeting. She apparently then began preparing dinner, setting sweet potatoes and utensils on the kitchen counter and placing frozen beef liver in a saucer to thaw. Then, she hung herself. Stafford found his wife around 11:00 a.m.

During August 1984, Pauline Stafford was hospitalized for a bladder disorder. Tests conducted during her stay revealed that she had lung cancer. Further tests determined, however, that the cancer had not spread to other parts of her body. Surgery performed in September 1984 to remove the lung cancer was apparently successful, and Pauline returned home with her doctors' assurances that the lung cancer had been removed, the cancer had not spread, and she stood a good chance of recovery.

Pauline received a CT scan test prior to surgery to determine whether the cancer had metastasized to her brain. Dr. Cohen, a neurologist and employee of NMI, read and interpreted the CT scan. He concluded, and everyone agreed at trial, that the test revealed no cancer. Dr. David Gardner, the cardiologist who evaluated Pauline to determine whether she should undergo surgery for lung cancer, told Pauline and Mr. Stafford that she did not have a brain tumor and that there was no evidence that the lung cancer had spread.

NMI charged the Staffords $129.00 for reading and interpreting the CT scan. Since Pauline was covered by Medicare, NMI submitted the charge to General American Insurance Company, the regional Medicare fiscal intermediary. Pauline signed a blank Medicare claim form titled HCFA form 1500. In accordance with Dr. Cohen's instructions, NMI's clerical staff then completed the claim information on the form, stamped it with Dr. Cohen's signature, and mailed it to General American.

Box 23A of HCFA form 1500 was titled "Diagnosis or Nature of Illness or Injury." Upon Dr. Cohen's instruction, an NMI employee wrote the words "brain tumor" in box 23A of Pauline's form. The appellees' position throughout trial was that while Pauline was never diagnosed as suffering from a brain tumor, General American prohibited the use of a "rule out diagnosis" when an HCFA form 1500 was submitted to obtain payment for a CT scan. Thus, for example, the form, using the accepted rule out abbreviation, could not be submitted with the phrase "R/O brain tumor" in box 23A. The appellees were thus forced to use, as they termed it, a provisional diagnosis. They contended this prohibition applied only to CT scans. Several witnesses testified that on prior occasions Dr. Cohen's office had submitted a rule out diagnosis to General American, and the form had been returned unpaid. Dr. Cohen's staff would then white-out the "R/O portion of the diagnosis, resubmit the form to General American, and ultimately receive the Medicare payment. Thus, Dr. Cohen and his associate, Dr. Sherrod, testified that while they would have felt more comfortable using rule out diagnoses on HCFA form 1500s, they felt compelled to follow General American's policy.

After receiving Pauline's HCFA form 1500, General American paid its portion of the claim and, apparently, sent a copy of the form to MJM Electrical Cooperative, the company through which the Staffords maintained a secondary insurance policy. MJM had standing orders from Stafford to send a copy of all insurance-related documents to his home. Accordingly, on either Friday, January 11, or Saturday, January 12, 1985, Stafford received a letter in the mail from MJM concerning the payment of Pauline's medical bill. He opened the letter around 4:00 p.m. on Saturday. Attached to the letter was the HCFA form 1500 containing the words "brain tumor" under the heading "Diagnosis or Nature of Illness or Injury." Stafford placed the form on the table. Pauline picked it up and read it.

Stafford testified that Pauline became withdrawn immediately after reading the form. Her actions over the next two days, while not unusual when viewed in the abstract, were in sharp contrast, according to Stafford, to her usual behavior and routines. After reading the claim form, Pauline did some ironing--something she had never done on a Saturday night--and then went to bed early. She stopped talking; when Stafford tried to talk to her, she did not reply. Stafford described Pauline as "deeply depressed" on Sunday, unable to carry on a conversation. She did remark, however, that she was going to call the doctor on Monday and "have him tell me the truth about the brain tumor." She went to bed early on Sunday, perhaps before 60 Minutes aired at 6:00 p.m. Stafford testified that they "usually solved all the problems of the world at the breakfast table," but on Monday morning they had no conversation. After breakfast, Stafford went outside to chop wood. When he returned, Pauline was dead.

Stafford brought this action, contending that Dr. Cohen and NMI negligently inserted the words "brain tumor" on the HCFA form 1500 and that their negligence caused Pauline's death. Stafford contended, and psychiatric expert Dr. David Shepard testified, that when Pauline learned of the incorrect brain tumor "diagnosis," it created an impulse control disorder that caused her impulsive suicide. Both defendants moved for a directed verdict at the close of the plaintiff's case and after the presentation of their evidence. These motions were denied. The jury returned a verdict against both Dr. Cohen and NMI, and awarded Stafford $200,000.

The district court reversed the jury's verdicts, granting judgment n.o.v. for both Dr. Cohen and NMI on the basis that the evidence failed to create a submissible jury issue on the element of proximate causation. The district court also conditionally granted a new trial.

II.

A judgment n.o.v. may be entered only if all the evidence points one way and is susceptible of no reasonable inferences sustaining the position of the non-moving party. E.g., Brown v. Syntex Laboratories, Inc., 755 F.2d 668, 671 (8th Cir.1985); Jasperson v. Purolator Courier Corp., 765 F.2d 736, 741 (8th Cir.1985). In applying this standard, the district court was required to consider all evidence in the light most favorable to Stafford, assume that the jury resolved all evidentiary conflicts in his favor, assume as true all facts the evidence tended to prove, and give Stafford the benefit of all favorable inferences that could be drawn from the facts proved. See, e.g., Gilkerson v. Toastmaster, Inc., 770 F.2d 133, 136 (8th Cir.1985); Midwest Communications, Inc. v. Minnesota Twins, Inc., 779 F.2d 444, 455 (8th Cir.1985), cert. denied, --- U.S. ----, 106 S.Ct. 2289, 90 L.Ed.2d 730 (1986).

Under Missouri law, Stafford was required to prove that the appellees' allegedly negligent acts--writing the words "brain tumor" on the HCFA form 1500 and sending it to General American--could "be reasonably regarded as a direct, producing or efficient cause; or as entering into and forming a part of the direct, producing or efficient cause of the injury." McConnell v. Pic-Walsh Freight Co., 432 S.W.2d 292, 297 (Mo.1968). "Proof of proximate cause may be established from either direct or circumstantial evidence." Hoover's Dairy, Inc. v. Mid-America Dairymen, Inc., 700 S.W.2d 426, 434 (Mo.1985) (en banc).

At trial Stafford attempted to prove, through expert testimony and circumstantial evidence, that Pauline's reading of the words "brain tumor" caused an impulse control disorder in that Pauline suffered from an irresistible impulse to kill herself. Under Missouri law, when a person's actions cause a victim to become "insane and bereft of reason" such that the victim involuntarily commits suicide, the person's actions can constitute the proximate cause of the death. Wallace v. Bounds, 369 S.W.2d 138, 143-44 (Mo.1963). An "irresistible impulse" is a form of insanity that could lead to an involuntary suicide. See, e.g., Lemmon v. Continental Casualty Co., 350 Mo. 1107, 169 S.W.2d 920 (1943); Garmon v. General American Life Insurance Co., 624 S.W.2d 42 (Mo.Ct.App.1981). See generally Restatement (Second) of Torts Sec. 455 (1965) (actor liable if his negligent conduct causes another's insanity, making it impossible for the other to resist an impulse caused by her insanity). Accordingly, the factual issue at trial was whether Pauline's learning of the "diagnosis" of brain tumor caused an impulsive suicide.

Dr. David Shepard, an...