Witte v. Azarian

WILNER, Judge. At issue before us is the proper construction of Maryland Code, § 3-2A-04(b)(4) of the Courts and Judicial Proceedings Article, which is part of the law dealing with the resolution of health care malpractice claims. Section 3-2A-04 requires that such claims, if seeking compensation in an amount that exceeds the jurisdiction of the District Court, be filed initially with the Health Claims Arbitration Office (HCAO). In 1986, the General Assembly amended the law to require that unless, within 90 days after the filing of the claim, the claimant files with the HCAO a certificate of a qualified expert attesting that the defendant’s conduct constituted a departure from the standard of care and that the departure was the proximate cause of the alleged injury, the claim must be dismissed with prejudice.

In the same Act, and with the apparent intention of limiting the class of experts who may issue such a certificate, the Legislature, in § 3-2A-04(b)(4), provided that “[t]he attesting expert may not devote annually more than 20 percent of the expert’s professional activities to activities that directly involve testimony in personal injury claims.” We need to determine what kinds of activities are to be counted in calculating the 20%. BACKGROUND In May, 1998, respondents Elizabeth and Mark Azarian filed a claim with the HCAO alleging negligence on the part of petitioner, Dr. Jeffrey Witte, in his medical treatment of Ms. Azarian’s fractured ankle. Within the time allowed by the statute, the Azarians filed a certificate of Dr. Lawrence Hon-ick attesting that (1) he was a licensed health care provider specializing in orthopedics, (2) less than 20% of his professional activities were devoted annually to activities that directly involved testimony in personal injury claims, (3) he had reviewed the records relating to medical treatment rendered to ⁵²² Ms. Azarian by Dr. Witte, and (4) the care and treatment rendered to her by Dr. Witte failed to comply with the standards of care and that failure was the proximate cause of the permanent injury to her left leg. Contemporaneously with the filing of that certificate, the Azarians waived arbitration pursuant to § 3-2A-06B, and, as a result, the case was transferred to the Circuit Court for Montgomery County, where they filed a complaint against Dr. Witte.

In April, 1999, defense counsel deposed Dr. Honick, who was then the Azarians’ sole identified medical expert on the issues of breach of care and proximate causation. Honick admitted that he had given up performing surgery about eleven years earlier, that, although he had “courtesy” privileges at two hospitals, he did not admit patients there, and that about 90% of his patients “have some sort of litigation involved in addition to their medical claims.” He added that “[mjany of these are workers’ compensation” cases and that “[mjost of them, to my knowledge, don’t even go to the lawsuit.” Upon further examination, he said that “a very small percent” of his work week was spent in testimony or review of records in medical malpractice cases, that he either appeared in court or attended a deposition about once a month, but that about 60% of his patients came from referrals from attorneys or workers’ compensation insurance carriers. Following that deposition, Witte filed a combined motion in limine and for summary judgment, the basis of which was that (1) in order to prevail, the Azarians were required to produce expert medical evidence that Witte departed from the applicable standard of care, (2) the only expert witness identified by the Azarians who could give such evidence was Dr. Honick, but (3) because Honick devoted more than 20% of his professional activities to activities that directly involved testimony, he was not qualified. Witte asked that the court bar Honick’s testimony and, in the absence of any other expert evidence as to standard of care, breach, and causation, enter summary judgment in his favor.

The court denied the motion, and trial commenced, before a different judge and a jury, in February, 2000. ⁵²³ On the third day of trial, after five other witnesses had testified, Dr. Honick was called. On voir dire examination, he iterated that his practice was entirely an office practice and that he no longer performed surgery. He said that he saw about 100 patients a week and that 75% to 80% of them were involved in some kind of injury. He acknowledged that 50% to 60% of his patients were referred by lawyers, that about half of those referrals were for evaluations only with no treatment involved, that he appeared at depositions between 300 and 400 times over a 30-year period, that he previously testified in another case that a “major percentage” of his income related solely to “forensic” matters, which included workers’ compensation, personal injury, and medical malpractice cases, and that 12 to 14 years ago he had placed one advertisement that he provided guidance, strategy, and planning in the development of medical aspects of cases.

Defense counsel took those admissions as evidence that Honick devoted more than 20% of his professional activity to activities directly involving testimony and renewed his motion (1) to preclude Honick from testifying, and (2) given that Honick was the physician who provided the statutorily required certificate, to dismiss the action. Although expressing the view that, when applied to a non-treating physician, the term “directly involve,” as used in § 3-2A-04(b)(4), was not limited just to testimony but included as well the examination of patients, preparing for depositions, writing reports, and reviewing records, the court reserved ruling on the motion and allowed additional voir dire examination. That examination produced further admissions that about 30% to 40% of Dr. Honick’s practice involved performing independent medical examinations and evaluations upon referrals from attorneys, workers’ compensation carriers, or other insurance carriers and that, as part of his work, he prepared a report to the referring attorney or carrier summarizing his findings and opinions. In most instances, he said, his report was sufficient but that occasionally he discussed his report with the attorney or adjuster.

Dr. Honick said that, in terms of time, as ⁵²⁴ opposed to percentages of patients, about 75% of his time was spent treating patients and the rest was spent on evaluations. In making its ultimate ruling, the court construed the statute as encompassing “activities that lead to testimony in personal injury claims, or could lead to testimony in personal injury claims.” (Emphasis added). It made clear that the test was not “whether it actually leads to personal injury claim testimony,” but rather whether “it could lead to it.” Using that standard, the court treated as activities directly involving testimony “the actual testimony, the testimony preparation, the review of records, the preparation of reports, and all other forensic activity ... [wjhether or not it results in testimony.” On the evidence presented, the court found that “25 percent of Dr. Honick’s time is devoted to the specific kind of activities which under [§ 3-2A-04(b)(4) ] cannot exceed 20 percent. That is, the professional activities that directly involve testimony in personal injury claims.” Upon that finding, the court concluded that the certificate was invalid and that, as a valid certificate is a condition precedent to the prosecution of a medical malpractice claim, the claim could not proceed.

The court therefore granted what it regarded as a renewed motion for summary judgment and entered judgment in favor of Witte. Rejecting the trial court’s “expansive construction of the phrase ‘directly involve testimony,’ ” the Court of Special Appeals reversed and remanded the case for further proceedings. Azarian v. Witte, 140 Md.App. 70, 99, 101-02 , 779 A.2d 1043, 1059, 1061 (2001). The intermediate appellate court determined, both on an analysis of legislative intent and because the statute served to restrict a common law action, that a narrower construction was appropriate.

Most medical evaluations, even those requested by lawyers or insurance companies, it noted, “are performed with little or no expectation that testimony will ever be required.” Id. at 101, 779 A.2d at 1060. “[Ojnly when a medical examination is performed in preparation for testifying,” the court declared, does the evaluation constitute activity that directly involves testimony, and only those activities “which are principally performed ⁵²⁵ to prepare for or engage in testifying” are within the ambit of the 20% limitation. Id. The court defined the category as including, in addition to actual testimony, “meetings, telephone conferences, the review of documents, the preparation of reports and other measures performed principally to prepare for or, as in the case of affidavits, in place of testifying as well as travel to and attendance at trial or depositions.” Id. It made clear, however, that actual testimony is not a prerequisite for “the preparatory activities to fall within the purview of the 20 percent limitation.” Id.

On that standard, it held that the evidence did not support the trial court’s conclusion that Dr. Honick violated the statutory limitation. It noted that, although he was asked about the number of times he testified and attended depositions and the percentage of his practice that involved personal injury matters, he was never asked how much time he spent preparing to testify or what part of his professional activities directly involved testimony in personal injury claims. Claiming that the Court of Special Appeals misinterpreted and failed to take proper account of the legislative intent behind § 3-2A-04(b)(4), Dr. Witte asks that we reverse its judgment. We disagree and shall therefore affirm its judgment.

DISCUSSION The parties agree that the issue before us is one of statutory construction and that, when engaged in such an endeavor, our goal is to ascertain and implement, to the extent possible, the legislative intent. In so doing, we look first to the words of the statute, on the tacit theory that the Legislature is presumed to have meant what it said and said what it meant. If the true legislative intent cannot readily be determined from the statutory language alone, however, we may, and often must, resort to other recognized indicia — among other things, the structure of the statute, including its title; how the statute relates to other laws; the legislative history, including the derivation of the statute, comments and explana ⁵²⁶ tions regarding it by authoritative sources during the legislative process, and amendments proposed or added to it; the general purpose behind the statute; and the relative rationality and legal effect of various competing constructions. See Beyer v. Morgan State University, 369 Md. 335, 349-50 , 800 A.2d 707, 715 (2002) and Liverpool v. Baltimore Diamond Exchange, Inc., 369 Md. 304, 317-19 , 799 A.2d 1264, 1272 (2002), in which we most recently stated these principles.

It is evident at a glance that the legislative intent as to which activities, other than the actual giving of testimony, are to be counted in determining the 20% is not clear from the words of the statute alone. Nothing is said about whether the conducting of medical examinations for the purpose of evaluation rather than treatment, or the writing of evaluation reports, or the reviewing of medical or other records for purposes of making an evaluation are to be included, and, if so, under what circumstances. In this regard, the phrase “directly involve testimony,” standing alone, is unclear and therefore ambiguous. Resort to other indications of the legislative intent is therefore required.

As we observed, the statute in question is part of the overall procedure devised by the General Assembly for the resolution of health care malpractice claims. That procedure first came into existence in 1976, as part of a multi-phase response to a malpractice insurance “crisis” that arose in 1974 when, as the result of being denied extraordinary rate increases by the Insurance Commissioner, the company that then insured about 85% of the physicians practicing in Maryland ceased offering medical malpractice insurance in the State. The immediate legislative response, aimed directly at providing alternative insurance coverage for the physicians, came in 1975 with the creation of the Medical Mutual Liability Insurance Society of Maryland, an insurance company chartered by the Legislature and capitalized through an assessment on licensed physicians. See 1975 Md. Laws, ch. 544; see also Report of the Joint Executive/Legislative Task Force on Medical Malpractice Insurance at 1-2 (Dec. 1985). ⁵²⁷ The General Assembly understood that the collapse of the malpractice insurance market was rooted, to some extent, in the manner in which malpractice claims arose and were resolved, and, along with its counterparts in other States that were experiencing similar problems, considered a variety of proposals designed to deal with those underlying issues.

It settled, in 1976, on (1) placing a finite limit on the period of limitations for bringing health care malpractice claims, (2) permitting medical malpractice insurers to settle claims within policy limits without having to obtain the approval of the insured health care provider and to make advance payments to claimants for medical costs, wage losses, and certain other expenses without such payments constituting an admission of liability, (3) requiring claims in excess of $5,000 — the then-existing jurisdictional limit of the District Court — to be submitted initially to non-binding arbitration, and (4) subjecting attorneys’ fees in malpractice actions to review and approval by the arbitration panel or the court. See 1976 Md. Laws, ch. 235. 1 The arbitration provisions created the HCAO and required all claims against a health care provider for damages due to medical injury to be filed with that office and submitted to arbitration before either a three-person panel, containing one attorney, one health care provider, and one lay person, or, if the parties so agreed, one arbitrator. A party could reject an award for any reason, provided it was done within the time and in the manner allowed, in which event, if the plaintiff wished to proceed further, a complaint would be filed in the Circuit Court and the case would either be settled there, dismissed on motion for some procedural defect, or tried de novo. Unless properly rejected, the arbitral award was binding and was to be confirmed by a Circuit Court. ⁵²⁸ The arbitration scheme was essentially placed “on ice” for about two years while challenges to its legality worked their way through the courts.

Not until after we rejected those challenges in Attorney General v. Johnson, 282 Md. 274, 313-14 , 385 A.2d 57, 80 , appeal dismissed, 439 U.S. 805 , 99 S.Ct. 60 , 58 L.Ed.2d 97 (1978), did the operation commence in earnest. Although the 1975-76 legislative response seemed to resolve the immediate “crisis” of insurance availability, opposition remained to the arbitration mechanism, and some concern was expressed that it did little to stem increases in the cost of malpractice insurance. In 1983, the General Assembly adopted a Senate Joint Resolution (S.J. Res. 14, 1983 Md. Laws J. Res. 9) declaring that the cost of medical liability insurance had increased ten-fold since 1975 and requesting the Governor to appoint a commission to study the problem. The commission appointed pursuant to that Joint Resolution — the Commission on Health Care Providers’ Professional Liability Insurance — found, in its January, 1984 Report to the Governor, that the assertion in the Joint Resolution was “significantly overstated” and that, although there had been significant increases in premiums for physicians in certain specialties, the overall rate of increase had not exceeded increases in the general cost of health care.

See Report of the Governor’s Commission on Health Care Providers’ Professional Liability Insurance at 2-3 (Jan. 1984). -Nonetheless, the Commission concluded that there were existing conditions and future dangers that warranted some changes in tort doctrines and the manner in which malpractice claims were processed. The Commission made a number of recommendations, including (1) abolition of the arbitration scheme created in 1976, (2) partial abolition of the collateral source rule, (3) a number of procedural changes designed to make the arbitration procedure more efficient and allowing the parties to waive arbitration altogether, if the arbitration procedure was not to be abolished, and (4) a requirement that a malpractice claimant file a certificate of a qualified expert, within 90 days after the filing of a claim, attesting to a departure from the standard of ⁵²⁹ care or of informed consent. As to the last of these, the Commission noted, without citation or specification, that measures of that type had been adopted in several other jurisdictions. The Commission’s recommendations, or at least some of them, were presented to the next (1984) session of the Legislature in the form of Senate Bill 16.

Among them was a requirement that a claim be dismissed if the claimant failed to file a certificate from a “qualified expert” attesting to a departure from the standards of care or informed consent within 90 days from the date of the complaint and a new provision, not noted in the Commission’s Report, that the “attesting expert may not receive more than 50% of the expert’s income from testimony and other activity related to health care malpractice claims.” Senate Bill 16 did not pass, which resulted in the formation of another study group, the Joint Executive/Legislative Task Force on Medical Malpractice Insurance. That task force, in its December, 1985 Report, noted that, since 1984, there had been increases ranging from 30% to 250% in medical malpractice liability insurance premiums for physicians in certain specialties and for hospitals. Among the issues considered by the Task Force were the severity and frequency of claims against health care providers, the effect of health claims arbitration, and the impact of the tort system in general on the cost of providing insurance coverage. Unlike