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Expert on Causation Required for Negligent Failure to Provide Medical Insurance


A company hired an employee and in the first few days of his employment, the employee submitted application forms to enroll in the health insurance plans the company offered. Four months after he was hired, the employee noticed that health insurance premiums were not being deducted from his paychecks, and he so informed the company's benefits coordinator. The benefits coordinator gave him a second set of enrollment forms for him to complete. Insurance premiums began to be deducted from his paychecks, paying for coverage retroactive to when he notified the company’s benefits coordinator that the premiums were not being deducted. Premiums continued to be deducted until the employee quit working for the company about a month later.

 

A month after the employee quit working for the company, he sought medical attention for breathing problems and discovered that he did not have health insurance. He contacted the company and was told he had no health insurance coverage. The company sent him a copy of a letter it had received from its insurer prior to him quitting, declining his insurance application due to its untimely submission. The company also sent him a check to reimburse him for the amounts deducted from his paychecks as health insurance premiums.

 

Two months after he quit working for the company, he went to the hospital seeking treatment for back pain. To help diagnose the back problem, the hospital recommended he get an MRI, which he could not afford without insurance, and the hospital refused to admit him without insurance. But the pain continued over the next few weeks and eventually caused him to be taken via ambulance to the hospital. The hospital admitted him and performed an MRI, which led to the diagnosis of a staph infection in his spine. He remained in the hospital for several days and stayed in a convalescent center for several weeks thereafter, but was still left with permanent back injuries after his recovery.

 

Over a year later, the former employee filed a lawsuit in federal court against the employer under the Employee Retirement Income Security Act (ERISA). The former employee was successful in that lawsuit, and the company was required to pay his medical bills. In the course of that litigation, he discovered new information underlying his insurance situation, which prompted him to bring a negligence action in state court against the company and its benefits coordinator for injuries allegedly caused by their failure to obtain health insurance coverage after premiums were taken out of his paychecks. Also, during the pendency of the federal case, he lost his sight in one eye, which he alleged was due to his inability to pay for laser surgery that would have treated his glaucoma and saved his sight. He further claimed that his mental health had deteriorated due to his lack of insurance and the problems flowing from it, and that he suffered from chronic depression.

 

The company and benefits coordinator moved for summary judgment on the ground that the discovery deadline had passed for identifying expert witnesses and the former employee had failed to identify any expert witnesses to show causation. The former employee argued that expert testimony was not necessary, pointing out that several of his treating physicians had been identified as fact witnesses during discovery. He alternatively requested leave to designate expert witnesses should the district court determine that such witnesses were necessary to prove causation. The Third District Court, Salt Lake Department, determined that expert testimony was necessary under the facts of the case, denied his request for leave to designate expert witnesses, and granted summary judgment in favor of the company and benefits coordinator.

 

The Court of Appeals of Utah affirmed. The court held that expert testimony was necessary to prove that lack of insurance caused the employee’s permanent back damage, blindness in one of his eyes, and depression, and the employee's disclosure of his intent to call his treating physicians as fact witnesses was not sufficient to allow the admission of their expert opinions on causation.

 

Expert testimony was necessary to prove that lack of insurance caused the employee’s permanent back damage, blindness in one of his eyes, and depression. The court reasoned that the need for positive expert testimony to establish a causal link between a defendant's negligent act and the plaintiff's injury depended on the nature of the injury. Where the injury involved obscure medical factors which were beyond an ordinary lay person's knowledge, necessitating speculation in making a finding, there must be expert testimony that the negligent act probably caused the injury. The court held that expert testimony was necessary to prove that the alleged negligence of the company and its benefits coordinator in failing to obtain health insurance coverage for the employee during his time of employment caused his permanently damaged back, blindness in his left eye, and depression. It was not within an ordinary lay person's knowledge whether an infection was present when the employee first started feeling back pain, whether an MRI at an earlier date would have led to an earlier diagnosis, whether the type of back injury sustained was likely the result of infection, or whether earlier commencement of treatment would have likely prevented any portion of the damages. The specifics or severity of glaucoma, the procedure recommended, and the likelihood that the employee would have been able to maintain sight in his eye had the procedure been done at the time it was recommended, were not within an ordinary lay person's knowledge. Depression was a complex ailment that could have stemmed from any one factor or a combination of an innumerable set of factors, and an ordinary lay person would not have known which factor or factors likely caused the former employee’s depression and would have been unable to determine, without speculation, whether he would have avoided depression if he had insurance. The court concluded that because the former employee failed to designate any witnesses to provide expert testimony to establish causation, judgment in favor of the company and its benefits coordinator on his negligence claims was appropriate as a matter of law.

 

The former employee's disclosure of his intent to call his treating physicians as fact witnesses was not sufficient to allow the admission of their expert opinions on causation. The court reasoned that the expert disclosure discovery rule contemplated that all persons who may provide opinion testimony based on experience or training will be identified, but that only retained or specially employed experts are required to also provide an expert report. Treating physicians do not fall into the category of “retained or specially employed” expert witnesses, and expert reports as mentioned in the expert disclosure discovery rule are not required for treating physicians who will testify as experts. Treating physicians must be disclosed as expert witnesses under the expert disclosure discovery rule if they will provide opinion testimony based on their experience or training. The court concluded that the former employee’s treating physicians were required to be designated as experts if they were to provide expert testimony. His disclosure of his intent to call his treating physicians as fact witnesses was not sufficient to allow the admission of their expert opinions, and he remained without any witnesses designated to give expert testimony as to causation.

 

The Court of Appeals of Utah affirmed the trial court’s grant of summary judgment in favor of the employer and coordinator.

 

See: Hansen v. Harper Excavating, Inc., 2014 WL 3747546, 766 Utah Adv. Rep. 13, 2014 UT App 180 (Utah App., July 31, 2014) (not designated for publication).

 

 

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