Ward v. Presbyterian Healthcare Services

Citations: 79 F. Supp. 2d 1276; 1999 U.S. Dist. LEXIS 20290; 1999 WL 1292910Docket: Civ.99-98 LFG/DJS

Court: District Court, D. New Mexico; October 7, 1999; Federal District Court

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Laura Ward, as the personal representative of her deceased daughter Valerie, filed a lawsuit against multiple defendants, including Presbyterian Healthcare Services and Presbyterian Health Plan, alleging violations of EMTALA and negligence per se. In her Second Amended Complaint, Ward claims that Presbyterian Salud breached a contract and violated 42 U.S.C. 1396u-2, while denying any EMTALA claims against that particular defendant. The court previously dismissed claims against Presbyterian Salud for negligent infliction of emotional distress and civil rights violations.

The facts reveal that on July 16, 1998, Laura took Valerie to UNM Family Health Center for evaluation by Dr. Ivan Pinon. Valerie’s insurance through Presbyterian Salud required evaluation at Presbyterian Kaseman Hospital (PKH) before inpatient care. After being told there were no available beds at PKH, Dr. Pinon attempted to refer Valerie to UNM Mental Health Center (UNMMHC), but was informed that her insurance would not cover admission there. Laura took Valerie to PKH, where she requested admission but was again told there was no space. PKH conducted no screening or evaluation. At UNMMHC, after signing in and waiting, they learned that UNMMHC was still waiting for PKH to authorize admission based on insurance coverage. The court is considering the motion to dismiss claims against Presbyterian Healthcare Services and Presbyterian Health Plan for failure to state a claim.

During an interview, Valerie, feeling agitated, was advised by an employee to go outside to smoke. Between 4:00 and 4:30 p.m., Laura noticed Valerie was missing and began searching for her. Valerie had left the facility, walked to a nearby building, and, between 4:45 and 5:00 p.m., tragically jumped from the fifth floor, resulting in her death. The current motion from PHS and Presbyterian Salud seeks to dismiss the plaintiff's claims regarding EMTALA violations and negligence per se against Presbyterian Salud. The plaintiff concedes in her response that there is no claim for EMTALA violation against Presbyterian Salud, rendering this aspect of the motion moot; thus, the court will grant the motion to dismiss any potential EMTALA claims.

The court must determine whether the plaintiff sufficiently stated a cause of action for negligence per se under 42 U.S.C. 1396u-2. The court finds that the plaintiff did not adequately support this claim and grants the defendants' motion to dismiss. Under Federal Rules of Civil Procedure 12(b)(6), the court accepts all well-pled allegations as true and considers if the plaintiff is entitled to present evidence for her claims.

For a negligence per se claim, the plaintiff must demonstrate four elements: a relevant statute, a violation of that statute by the defendant, that the plaintiff belongs to the protected class, and that the harm suffered is of the type the statute aims to prevent. The court rejects the assertion that 42 U.S.C. 1396u-2 establishes a standard of conduct for managed care organizations regarding enrollees. The plaintiff failed to allege sufficient facts to support a violation of this statute, which does not impose individual duties like EMTALA. Instead, 1396u-2 pertains to state obligations concerning managed care entities and outlines requirements for contracts with these entities, including enrollment guidelines, provision of emergency services, and access to necessary care.

Subsection (c) mandates the development and implementation of a quality assessment and improvement strategy, including an independent external review of managed care activities. Subsection (d) restricts managed care entities' activities to prevent fraud and abuse, outlining state procedures for handling noncompliance. Subsection (e) details the sanctions the state can impose for enforcement. Subsection (f) stipulates that all relevant contracts must include a timeliness of payment clause. Remedies for noncompliance with provisions of 1396u-2 are strictly state-imposed sanctions. Managed care organizations must implement internal grievance procedures for enrollees to contest denial of coverage, and both the state and managed care entities must inform enrollees about these procedures.

Section 1396u-2 serves as an administrative tool for states to manage Medicaid effectively, ensuring a comprehensive range of medical services for beneficiaries while outlining necessary procedures and requirements for managed care entities. It does not specifically protect any particular class of individuals but facilitates the broader management of Medicaid benefits.

The plaintiff's claim against Presbyterian Salud lacks specificity concerning the alleged violations of 1396u-2 that contributed to her daughter's death. The complaint generically asserts that Presbyterian Salud was required to provide emergency behavioral health services and adequate capacity for Medicaid beneficiaries but fails to clearly cite how these obligations were violated. The plaintiff identifies subsections of 1396u-2 that purportedly impose negligence per se liability, but the court finds that the definitions and beneficiary protections stated do not establish a sufficiently specific duty to form a tort claim. The contract's inclusion of required provisions is not contested, and thus the complaint does not adequately support a claim of negligence per se under 1396u-2.

Plaintiff's Second Amended Complaint asserts that Presbyterian Salud is a for-profit health maintenance organization in New Mexico, serving as Valerie Ward's health insurance provider, with coverage limited to psychiatric care at Presbyterian Kaseman Hospital. The complaint claims Presbyterian Salud entered into a contract with the State of New Mexico and Valerie to provide behavioral health services but allegedly violated its duties under 42 U.S.C. § 1396u-2. However, these allegations do not sufficiently support a negligence per se claim because the plaintiff has not established that the statute imposes a standard of conduct on managed care organizations or that Presbyterian Salud violated the statute or denied benefits to the decedent. Consequently, the court grants the motion to dismiss the EMTALA and negligence per se claims for failure to state a claim. The Statement of Facts is taken as true per Federal Rule of Civil Procedure 12(b)(6).