Johns Hopkins Hospital v. Lehninger

Couch, J., delivered the opinion of the Court. In 1979 James W. Lehninger sued The Johns Hopkins . Hospital (the Hospital) alleging that he suffered a serious disability because of negligent acts committed by the Hospital’s agents in 1971 and 1973. The Hospital answered the declaration by denying the alleged wrongs, and invoking the applicable statute of limitations.

At trial the court granted a directed verdict in favor of the Hospital as to the running of the statute of limitations. Issues were submitted to the jury, however, concerning whether the Hospital was negligent and whether this negligence estopped the Hospital from raising the defense of limitations. The jury answered these issues in Lehninger’s favor and awarded him two million dollars ($2,000,000.00). On appeal the Hospital, appellant, presents three questions for our consideration: ⁵⁵¹ I. Should the case have been submitted to arbitration, under the terms of the Health Care Malpractice Claims Act, Md. Cts. & Jud.

Proc. Code Ann. §§ 3-2A-01, et seq., as a condition precedent to trial?

II

Did the trial court err in permitting consideration by the jury of whether the appellant should have been estopped from asserting the defense of limitations?

III

Was prejudicial error committed in permitting an economist to project the future > earning capacity of Lehninger on the basis of flawed and speculative economic methodology? For the reasons set forth in this opinion we hold that the case was properly heard in the trial court rather than in an arbitration proceeding. Nevertheless, we hold that the judgment of the trial court must be reversed, and the case remanded for dismissal without a new trial, because the trial court erred in permitting the jury to consider whether the appellant should have been estopped from asserting the defense of limitations. Because our latter holding disposes of the case, we need not address the appellant’s third question.

The Facts In 1971 James W. Lehninger, appellee, attended the Johns Hopkins University as a third-year medical student. On January 10, 1971, while walking up a Pennsylvania ski slope, Lehninger slipped on ice and fell against his right hip. Because of the pain and discomfort in his hip, Lehninger returned to Baltimore. The next day, January 11, 1971, Lehninger went to the Student Clinic of The Johns Hopkins Hospital.

His medical history was recorded, and an x-ray was taken of the right hip. A physician-employee of the Hospital, Dr. Jacobs, then advised Lehninger that "the x-ray looked fine and there was ⁵⁵² no fracture.” Lehninger learned that his injury was diagnosed as "just a bruise or a strain,” requiring him to "take it easy for a couple of days.” The clinic provided him with a cane, and the clinic’s physician told Lehninger that he could place weight on the right leg. Despite chronic severe pain, Lehninger resumed his student activities. On January 14, 1971, while walking to his car, Lehninger slipped on the icy pavement and again fell on his right hip.

Unable to move himself, Lehninger was carried by friends to his apartment, and later taken by ambulance to the Johns Hopkins Hospital. An x-ray taken at the Hospital’s emergency room revealed a displaced fracture of the femoral neck of Lehninger’s right hip. Immediate surgery was performed involving the reduction of the fracture and the insertion of metal hardware referred to as a Knoll’s pin and a Ken nail. This procedure secured the fracture site, and required that the hardware remain in place in the hip for almost two years.

Following treatment and periodic x-rays of his hip, Lehninger completed medical school in June, 1972. He moved to California and began an internship. Lehninger returned to the Hospital on December 16, 1973. An additional x-ray was taken, and the metal hardware was removed on December 18, 1973.

Dr. Robinson, Chief of the Hopkins’ Department of Orthopedics, who performed the January 14,1971 surgery, assured Lehninger that the x-ray showed the hip to be free of any abnormality, and not requiring further.orthopedic treatment. Lehninger was told that he could resume his usual activities after a brief recuperation. Lehninger returned to California, continued his work as a resident physician, and eventually resumed a regimen of strenuous physical exercise. Soon his leg felt fine enough to permit him to run long distances and play tennis daily.

During the late summer of 1977, while playing tennis, Lehninger felt "something snap” in his leg. A chronic pain developed in his right hip, and after several days he visited ⁵⁵³ Dr. Finerman, a Los Angeles orthopedist. In September of 1977, Lehninger was informed that he "had a serious disease ... called avascular necrosis.” Avascular necrosis is a condition of bone deterioration or bone death resulting from the disruption of the blood supply to certain areas of the skeletal system. After returning to Baltimore, Lehninger again saw Dr. Robinson, who consulted another orthopedist, Dr. Hungerford.

Having reviewed the x-ray made in December of 1973, Dr. Hungerford wrote on October 31, 1977 that Lehninger’s condition was "suggestive of the possibility of avascular necrosis.” Films dated October of 1977 showed Dr. Hungerford a "significant collapse” of certain segments of Lehninger’s femur. During the next year Lehninger obtained his medical records from the Hospital, and consulted with physicians in Boston and Philadelphia. On April 16, 1979, Lehninger filed suit against the Hospital alleging that the Hospital’s agents: (1) on January 11, 1971 negligently informed Lehninger that his hip was normal, having failed to diagnose his injury as an undisplaced fracture, and (2) on or about December 24, 1973, negligently assured Lehninger that he would not develop a bone disease. Trial commenced in the Baltimore City Court on May 27, 1980.

Evidence at the trial revealed that the x-rays of Lehninger’s initial injury, taken on January 11, 1971, were examined by Dr. DiSimone, a radiologist at the Hospital. In a report dated January 13, 1971 Dr. DiSimone interpreted these x-rays to be normal, and not showing a definite fracture. Thus, he confirmed the diagnosis given to James Lehninger by Dr. Jacobs. Dr. DiSimone testified that competent radiologists, acting within their standard of care, would probably have interpreted the January 11th x-ray as showing a normal hip.

Under cross-examination, however, the witness stated that soon after James Lehninger’s second fall and injury, the ⁵⁵⁴ January 13th report concerning the initial injury was amended. The amendment reflected the possibility of a "subtle impacted fracture of the neck of the right femur.” Testifying for the plaintiff, Dr. Schoedinger, an orthopedic surgeon, stated that the x-ray taken on January 11, 1971 showed clear evidence of a fracture. A pathologist, Dr. Combs, concurred in this opinion of the severity of the initial injury. After the surgery of January 14, 1971 for the subsequent fracture James Lehninger learned from Dr. Robinson of the serious nature of the first fracture.

Dr. Robinson testified that on January 14, 1971 he discussed James Lehninger’s prognosis with the patient’s father, Dr. Albert Lehninger, a professor of biochemistry. Dr. Robinson had described the possible complications of the bone displacement injury, how such an injury could affect the femur’s blood supply, and could cause avascular necrosis. Albert Lehninger confirmed the substance of that conversation, but testified that the discussion occurred within two weeks after the operation, rather than immediately afterwards. James Lehninger similarly testified that, on several occasions during the first year after his injury, he discussed with his doctors the possibility of medical complications, especially avascular necrosis.

He received repeated assurances that he had not developed bone disease. Hospital doctors provided these assurances, based on their interpretation of x-rays taken periodically during 1971 and 1972. James Lehninger did not learn until years later that a "liver scan” test conducted on June 8, 1971 produced what Dr. Robinson reported in September, 1971 as "very tenuous evidence of avascular necrosis in the right femoral head.” This test was conducted during a medical examination of Lehninger for problems of weakness and low-blood sugar unrelated to the hip injury. Uncontradicted testimony indicated that the liver scan was not designed to diagnose avascular necrosis, and that the presence of metal hardware ⁵⁵⁵ in Lehninger’s hip could have affected the test’s results.

The correct diagnostic tool for avascular necrosis was stated to be x-rays. On the basis of his interpretation of the x-ray dated December 17, 1973, Dr. Robinson reassured Lehninger that no evidence indicated avascular necrosis. In December of 1973 Lehninger was also informed that he probably would not develop the disease in the future, because, as he testified, "if I was going to get it I would have gotten it by then, so there was no need for any further x-rays.” Expert witnesses for Lehninger testified that the December 17, 1973 x-ray showed "an early change” indicative of avascular necrosis. The Hospital’s witnesses stated their opinion that this x-ray did not disclose avascular necrosis.

Lehninger testified at the trial that following the 1977 manifestation of the extent of his injury, he suffered difficulty in walking long distances without the use of crutches. The injury impeded his mobility in hospital wards, and prevented his working in private practice, according to Lehninger. He decided, therefore, to restrict his career to medical research and teaching. An economist indicated that Lehninger’s career restriction would result in a substantial loss of future income.

At the close of all evidence in the case, the Hospital filed a motion for mistrial or for directed verdict. On June 9, 1980, the trial judge granted a directed verdict in favor of the Hospital as to the running of the three-year statute of limitations. This ruling was based on an essentially undisputed finding that Lehninger discovered the alleged negligence of January 11, 1971 soon after he sustained the displaced fracture of January 14, 1971. Based on the insufficient evidence of any intentional or otherwise fraudulent concealment of Lehninger’s condition, the trial judge ruled that the statute of limitations had not been tolled by fraud under Md. Cts. & Jud.

Proc. Code Ann. § 5-203. The trial judge, however, ruled that the issues of estoppel and negligence should be submitted to the jury. The jury ⁵⁵⁶ found in Lehninger’s favor on these issues.

The trial judge also ruled against the Hospital on its motions for judgment n.o.v. or for new trial. The Hospital filed an appeal; no cross-appeal was taken by Lehninger. The Law I. Arbitration As a threshold question on appeal, the Hospital challenges the jurisdiction of the Baltimore City Court in hearing this case without the action’s prior filing with the Maryland Health Claims Arbitration Office. At the trial level the Hospital moved to dismiss the case contending that Lehninger failed to exhaust his remedies under the Health Care Malpractice Claims Act, now codified at Md. Cts. & Jud.

Proc. Code Ann. §§ 3-2A-01, et seq. The trial court denied the Hospital’s motion, and we affirm that decision. The legislature enacted the Health Care Malpractice Claims Act (the Act) as a means of alleviating a perceived crisis in the area of medical malpractice insurance.

See generally, Attorney General v. Johnson, 282 Md. 274 , 385 A.2d 57 , appeal dismissed, 439 U.S. 805 (1978). The Act requires submission of medical malpractice claims to non-binding arbitration prior to filing of an action in damages, for more than $5,000.00, in any Maryland court. See Bishop v. Holy Cross Hospital, 44 Md. App. 688 , 410 A.2d 630 (1980). Section 5, Chapter 235, Acts 1976 of the Act sets forth the effective date of the Act’s preceding elements, stating that: "[T]his Act shall take effect July 1,1976 and shall apply only to medical injuries occurring on or after that date.” The Hospital contends, without authority, that the Act applies to all health care claims filed after the effective date of the Act, regardless of the date of the occurrence of the "medical injuries.” Alternatively, the appellant argues that the Act should apply in the present case because Lehninger’s ⁵⁵⁷ medical injuries continued to manifest themselves after the Act’s effective date.

Our recent decision in Dennis v. Blanchfield, 48 Md. App. 325 . 428 A.2d 80 (1981), controls the issue of jurisdiction under the Act. In Dennis we rejected a physician’s argument that the Act required arbitration of a claim filed in June of 1977 concerning medical injuries which occurred in March and April of 1976. We held that the Act did not bar the Circuit Court for Prince George’s County from hearing the action without prior arbitration. In the present case we again find, the patient having sustained medical injuries prior to the effective date of the Act, that the trial court had jurisdiction to hear the case.

We hold that the trial court committed no error in denying the Hospital’s motion to dismiss.

II

Equitable Estoppel A. No Replication Requirement In its brief the Hospital states that Lehninger did not raise the issue of equitable estoppel, as a matter separate and distinct from fraudulent concealment, until after the close of all evidence in the case. The appellant then quotes the trial judge’s characterization of the equitable estoppel issue as being "a late starter.” In its reply brief the appellant explains that these references demonstrate the appellee’s failure to give notice of the intention to invoke equitable estoppel as a bar to the defense of limitations. The appellant concludes that Lehninger’s assertion of the equitable estoppel theory was improper and should not have been heard. Maryland case law, according to the Hospital, required Lehninger to file "a special pleading raising the replication of estoppel.” The Hospital refers us to the cases of Bean v. Stuart Petroleum Company, 244 Md. 459 , 224 A.2d 295 (1966), and Bitting v. Home Insurance Company, 161 Md. 56 , 155 A. 329 (1931).

In these cases the Court of Appeals either stated ⁵⁵⁸ or implied that equitable estoppel must be specially pleaded when it is relied on to avoid a defense set up in a special plea. Bean and Bitting , however, must not be relied on because Md. Rule 312 (a) eliminated any general requirement for filing a replication to a responsive pleading, either at law or at equity. The Committee note for this rule explains that in 1974 Md. Rule 312 (a) was readopted without change for the specific purpose of negating any inference in the case law that a replication is required to a plea of limitations or any other plea. The Hospital contends that in the absence of a special pleading, it had no notice of Lehninger’s intent to invoke equitable estoppel.

The record shows, however, that the Hospital’s counsel did not raise the issue of notice when Lehninger’s counsel shifted their argument from estoppel by fraudulent concealment to equitable estoppel by negligent misrepresentation. The issue of notice was not even presented in the appellant’s brief, but first appears in the reply brief. The trial court properly considered the application of equitable estoppel. B. No Estoppel of Defense of Limitations Having directed verdicts in favor of the Hospital concerning the absence of fraud and the running of the statute of limitations, the trial judge reached a "tentative conclusion” that equitable estoppel as a bar to the defense of limitations remained a "legitimate issue for submission to the jury.” Counsel for the Hospital objected and argued against this conclusion.

Explaining his conclusion to counsel, the trial judge stated in pertinent part: "With respect to 5-203, even if there were a fraudulent concealment of evidence of avascular necrosis, it was not concealment of the cause of ⁵⁵⁹ action. It was concealment of that injury and what 5-203 deals with is concealment of the cause of action. 5-203 does require proof of actual fraud as Mr. King has maintained. But we don’t reach that issue because the evidence is clear that the cause of action was not concealed. The most it could be said to be concealed was the presence or greater risk of avascular necrosis.

However, even though the professional malpractice decisions of the Court of Appeals seem to indicate, perhaps somewhere can be argued to indicate, that estoppel is inapplicable. As I read those cases in light of the line of equitable estoppel cases, I perceive that what the Court of Appeals is talking about is the parameters of the Discovery Rule and not the question whether or not in a given fact situation equitable estoppel could be invoked to prevent the defendant from invoking the statute of limitations.. .. And I think that the dictum in those cases which touches on the estoppel issue goes no further than to say that in this case we do not have sufficient evidence to give rise to equitable estoppel.... If one can sue and recover for negligent misrepresentation, it seems to me that those same facts would give rise to an estoppel to invoke the statute of limitations so that is sort of one of the basis for my conclusions.

The facts in this case give rise to an estoppel issue.” The court then instructed the jury as follows: "The law requires a plaintiff to file suit within a given period of time after the events complained of have occurred. This law is called the Statute of Limitations. In this case, the plaintiff did not file suit within the time required by the statute and the defendant has asserted the defense of limitations. The question to be answered by issue three is whether the defendant should be prevented from asserting the defense of limitations.

A defendant may be prevented from asserting the defense of ⁵⁶⁰ limitations if he has intentionally or negligently misrepresented any facts to the plaintiff, and the plaintiff in reliance on the misrepresentation has failed to file suit on time. In order for the defendant to be prevented from asserting the defense, the plaintiff must show it is more likely so than not, one, that the defendant intentionally or negligently misrepresented facts to the plaintiff. Two: That the plaintiff relied on the misrepresentation. And three: That because of the reliance on the misrepresentation failed to file suit on time.

The defendant is not prevented from asserting the defense of limitations if the suit was not filed on time because of the plaintiffs own lack of diligence. The underlying question is whether under the particular facts of this case, it would be unfair to permit the defendant to assert the defense of limitations. Now, with those things in mind your answer to question — or issue number three would be either yes or no.” [Emphasis added]. After deliberation, the jury found the Hospital negligent with respect to diagnosis and treatment during the period of January 11 to 13, 1971; that this negligence caused Lehninger’s injury; and that damages for this injury would be assessed in the amount of two million dollars ($2,000,000.00).

The Hospital was also found negligent with respect to diagnosis and treatment conducted on December 17, 1973, and that Lehninger was injured by that negligence. No damages were assessed, however, for the latter negligence. Importantly, the jury decided that the Hospital should "be prevented from asserting the defense of limitations.” On appeal the Hospital renews its contention that as a matter of law the principle of equitable estoppel should not have barred the defense of limitations in the present case. The appellant supports its contention with references to ⁵⁶¹ cases in which Maryland courts refused to extend the doctrine of equitable estoppel to preclude a statutory defense, in the absence of fraud.

The appellee opposes this assertion by citing cases in which courts have estopped parties from raising