Sixth Circuit rules that third parties may sue for damages under EMTALA

On April 6, 2009, the U.S. Court of Appeals for the Sixth Circuit (Sixth Circuit) ruled that a third party who suffers harm because of a hospital’s failure to screen or stabilize a patient with an emergency medical condition has standing to sue a hospital under the Emergency Medical Treatment and Active Labor Act (EMTALA). (Moses v. Providence Hospital and Medical Centers, Inc., 6th Cir. No. 07-2111 4/6/09). EMTALA is a federal statute that imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC) regardless of an individual's ability to pay. Hospitals are then required to provide stabilizing treatment for patients with EMCs.

In the Moses case, the plaintiff was the estate of Marie Moses-Irons (Moses-Irons). Moses-Irons took her husband (Christopher Howard), to the emergency room (ER) at Providence Hospital. Howard exhibited numerous physical symptoms, such as severe headaches, high blood pressure, vomiting, slurred speech, disorientation, hallucinations and delusions. Moses-Irons advised the ER staff that Howard had demonstrated threatening behavior, which made her fearful for her safety. Howard was evaluated by hospital staff and admitted as an inpatient for further testing and treatment. Several doctors, including a psychiatrist (Paul Lessem, MD), who recommended that he be transferred to the psychiatric unit for further assessment if his insurance would provide coverage, examined Howard. The transfer did not occur—there was no evidence that that patient’s insurance company denied coverage—and Howard was discharged six days after he was admitted. There is some question, due to inconsistencies in the documentation in the medical record, as to whether Howard was stable at the time of his discharge. Ten days after being discharged, Howard murdered Moses-Irons.

The plaintiff (estate of Moses-Irons) filed a federal suit against the hospital and Doctor Lessem, alleging a violation of EMTALA. The district court dismissed the estate’s EMTALA claims against the hospital because it concluded the hospital satisfied its obligations under ETMALA by admitting Howard and providing him with a complete screening, which showed no EMC—it did not address the issue of whether a non-patient (third party) has standing to sue under the EMTALA statute. The district court dismissed the action against Doctor Lessem based on the fact that there is no private right of action against individuals under EMTALA.

The plaintiff appealed to the Sixth Circuit. As anticipated, the Sixth Circuit upheld the district court’s decision related to the EMTALA claim against Doctor Lessem. The remainder of the decision took the health law community by surprise—the Sixth Circuit reversed the dismissal against the hospital on the EMTALA claim and interpreted a hospital’s obligations under the EMTALA statute more expansively than any other court. The most noteworthy aspects of the Sixth Circuit’s opinion are noted below.

• Third parties have standing to sue under EMTALA: The district court did not address the issue of whether a non-patient (third party) would have standing to sue under EMTALA—the Sixth Circuit did address this issue and held that a third party does have standing. In reaching this decision, it relied on the plain language of EMTALA, which states that an action can be brought by “any individual who suffers harm as a direct result” of a hospital’s EMTALA violation. The Sixth Circuit acknowledged the legislative history cited by the defendants, but noted that it should not rely on that as the exclusive explanation of the meaning of the EMTALA statute, especially when this differs from the actual wording of the statute. The opinion noted that this interpretation may have consequences for hospitals that Congress may or may not have considered or intended, but that the court’s duty was to read the statute as written, which does not preclude a third party from suing under EMTALA.
• A hospital’s EMTALA obligations do not end upon inpatient admission of a patient: Despite rules promulgated by the Centers for Medicare & Medicaid Services (CMS) (see reference) stating that the admission of an individual as an inpatient satisfies the hospital’s obligations under EMTALA, the Sixth Circuit held that “a hospital may not release a patient with an EMC without first determining that the patient has actually stabilized, even if the hospital properly admitted the patient”.
• Existence of EMC: The Sixth Circuit held that the plaintiff’s claim against the hospital should not have been dismissed because there were questions of fact regarding whether Howard had an EMC. The court went further and noted that a mental health emergency could qualify as an EMC under the plain language of the EMTALA statute.

While the Sixth Circuit’s opinion is not binding on states outside of the Sixth Circuit’s region (Ohio, Michigan, Kentucky and Tennessee), the opinion will be reviewed and considered by other courts reviewing this issue. As a result, hospitals throughout the country should be closely reviewing their policies and procedures related to EMTALA.

Reference
1. 42 C.F.R. § 489.24 (a)(1)(ii) and 489.24 (d)(2)(i) Click here to view.