Case Title: Loudin v. Radiology & Imaging Services, Inc.

Citation: 2011-Ohio-1817

Docket Number: 20100297

State: ohio

Court: Ohio Supreme Court

Date: 2011-04-20T00:00:00Z

Document:
[Until this opinion appears in the Ohio Official Reports advance sheets, it may be cited as 
Loudin v. Radiology & Imaging Servs., Inc., Slip Opinion No. 2011-Ohio-1817.] 
 
 
 
 
NOTICE 
This slip opinion is subject to formal revision before it is published in 
an advance sheet of the Ohio Official Reports.  Readers are requested 
to promptly notify the Reporter of Decisions, Supreme Court of Ohio, 
65 South Front Street, Columbus, Ohio 43215, of any typographical or 
other formal errors in the opinion, in order that corrections may be 
made before the opinion is published. 
 
SLIP OPINION NO. 2011-OHIO-1817 
LOUDIN, APPELLEE, v. RADIOLOGY & IMAGING SERVICES, INC., ET AL., 
APPELLANTS. 
[Until this opinion appears in the Ohio Official Reports advance sheets, it 
may be cited as Loudin v. Radiology & Imaging Servs., Inc.,  
Slip Opinion No. 2011-Ohio-1817.] 
Damages for emotional distress stemming directly from a physical injury are to 
be considered in a traditional medical-malpractice claim — Emotional 
distress stemming directly from a physical injury is not a basis for an 
independent cause of action for the negligent infliction of emotional 
distress. 
(No. 2010-0297 — Submitted January 18, 2011 — Decided April 20, 2011.) 
APPEAL from the Court of Appeals for Summit County, No. 24783, 
185 Ohio App.3d 438, 2009-Ohio-6947. 
__________________ 
SYLLABUS OF THE COURT 
1.  Damages for emotional distress stemming directly from a physical injury are to 
be considered in a traditional medical-malpractice claim. 
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2.  Emotional distress stemming directly from a physical injury is not a basis for 
an independent cause of action for the negligent infliction of emotional 
distress. 
__________________ 
MCGEE BROWN, J. 
{¶ 1} This is an appeal from a judgment entered by the Ninth District 
Court of Appeals finding that Lonna Loudin presented genuine issues of material 
fact that would allow her medical-malpractice claims to survive summary 
judgment.  We affirm the judgment of the court of appeals and hold that damages 
for emotional distress stemming directly from a physical injury are to be 
considered in a traditional medical-malpractice claim and that emotional distress 
stemming directly from a physical injury is not the basis for an independent cause 
of action for the negligent infliction of emotional distress. 
Facts and Procedural History 
{¶ 2} From 1997 through 2004, the appellee, Loudin, went to Reflections 
Breast Health Center (“Reflections”), owned and operated by Radiology & 
Imaging Services, Inc. (“Radiology”), to receive yearly mammograms.  All of 
Loudin’s mammograms during that time were interpreted as normal.  This 
included the mammogram conducted in 2003, which was reviewed by Dr. 
Richard Patterson in April of that year. 
{¶ 3} Loudin was persistent in monitoring herself for cancer because her 
husband had died of lung cancer in 1981 and she wanted to ensure early detection 
and treatment if she had cancer so that the same fate would not befall her.  In the 
spring of 2004, Loudin detected a lump in her left breast during self-examination 
and was referred to Reflections for a diagnostic mammogram.  The films from 
Loudin’s May 2004 mammogram revealed a mass that was highly suggestive of 
malignancy.  According to expert witness testimony, the mass had grown from 
one centimeter to approximately two centimeters between 2003 and 2004.  Dr. 
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David B. Dellinger conducted a biopsy of the mass, and the pathology report 
indicated that the mass was cancerous.  With no additional factors present, a two-
centimeter cancerous mass constitutes Stage I cancer.  Upon review of the 
pathology report of the biopsy, Dr. Joseph Koenig, Loudin’s oncologist, informed 
Loudin that her treatment plan would probably entail lymph-node dissection, a 
lumpectomy, radiation therapy, and hormone therapy, but would most likely not 
include chemotherapy if her lymph nodes tested negative for cancer.  Dellinger 
and Koenig recommended the dissection of nearby lymph nodes in order to 
determine whether Loudin’s cancer had spread to other areas.  Two of the eight 
lymph nodes dissected tested positive for cancer.  This additional factor advanced 
Loudin’s diagnosis to Stage IIA cancer.  Loudin underwent a lumpectomy, eight 
rounds of chemotherapy, six weeks of radiation therapy, and began hormone 
therapy.  At the time of her October 2005 deposition, Loudin’s cancer had not 
recurred. 
{¶ 4} Loudin initiated this action by filing a complaint asserting medical-
negligence claims against the defendants-appellants, Radiology & Imaging 
Services, Inc., Radiology & Imaging Services, Inc., d.b.a. Reflections Breast 
Health Center, and Dr. Richard D. Patterson.1  In her first claim for relief, Loudin 
alleged that Radiology, as the employer and principal to its employee physicians, 
including Patterson, had “caused and/or contributed to her injury.”  In her second 
claim for relief, Loudin alleged that Patterson had breached the required standards 
of care when conducting Loudin’s regular screenings for breast cancer.  In her 
third claim for relief, Loudin alleged that Radiology had negligently failed to 
supervise Patterson.  Loudin alleged injuries in the form of a delayed diagnosis of 
cancer, the progression of untreated carcinoma to Stage IIA breast cancer, the 
                                                 
1 Loudin first filed a complaint on April 14, 2005, but voluntarily dismissed the matter without 
prejudice on March 16, 2007.  On March 14, 2008, she refiled her complaint as permitted by R.C. 
2305.19, which allowed her complaint to stay within the one-year statute of limitations applicable 
to medical claims under R.C. 2305.113(A). 
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“loss of chance for a better outcome,” emotional distress, acute physical, mental, 
and emotional pain and suffering, and a loss of the ability to enjoy a normal life. 
{¶ 5} In her claims for medical negligence, respondeat superior, and 
negligent supervision, Loudin alleged that the appellants had breached the 
required standard of care by failing to detect and commence treatment for her 
cancer upon examination of her 2003 mammography films, which revealed a 
visible one-centimeter mass.  Upon being granted leave, Loudin amended her 
complaint on March 5, 2009, to further allege that the appellants’ negligence had 
led to the enlargement of her tumor, metastasis to her lymph nodes, and emotional 
distress from the fear of an increased chance of recurrence of cancer. 
{¶ 6} Loudin submitted the deposition testimony of radiologist Dr. Jules 
H. Sumkin, who stated that the failure to detect her cancer in 2003 was a 
deviation from the applicable standard of care and that Loudin’s tumor had 
increased from one centimeter to two centimeters from 2003 to 2004.  Loudin also 
submitted the deposition testimony of an additional expert witness, Dr. Ronald 
Citron, who stated that to a reasonable degree of medical certainty, the cancer 
would not have been present in Loudin’s lymph nodes had she been correctly 
diagnosed in 2003.  With lymph nodes negative for cancer and a one-centimeter 
cancerous tumor, Loudin still would have undergone a lumpectomy, radiation 
therapy, and hormone therapy.  However, with lymph nodes testing positive for 
cancer, she also had to undergo chemotherapy.  Citron testified that Loudin’s ten-
year-survival prognosis would have been 85 percent had detection and treatment 
occurred in 2003 and that her prognosis from detection and treatment in 2004 was 
82 percent. 
{¶ 7} Ultimately, the appellants filed a motion to dismiss Loudin’s 
amended complaint for failure to state a claim for which relief could be granted.  
The appellants characterized Loudin’s complaint as seeking recovery solely for 
the negligent infliction of emotional distress.  In their response to Loudin’s 
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memorandum opposing their motion, the appellants also argued that Loudin had 
not established her medical-negligence claim. 
{¶ 8} Because both parties’ arguments relied on facts outside the 
pleadings, the trial court converted the appellants’ motion to dismiss into a motion 
for summary judgment.  In its decision, the trial court noted that Loudin had 
included damages for emotional distress in her medical-malpractice claim, but 
had not pleaded a separate cause of action for the negligent infliction of emotional 
distress.  The trial court nonetheless chose to separately address Loudin’s request 
for damages for emotional distress using the analysis applied to claims for 
negligent infliction of emotional distress.  The trial court concluded that Loudin 
was precluded from making a claim for the negligent infliction of emotional 
distress because such a claim would require the finder of fact to determine what 
portion of Loudin’s emotional distress was attributable to her initial diagnosis of 
cancer and what portion was attributable to “her understanding that the untreated 
cancer had metastasized, thereby changing her diagnosis for the worse.”  And this 
type of determination, the court held, was “precisely the type of issue that courts 
have attempted to guard against in their analyses of these types of claims.”  The 
trial court also concluded that Loudin’s medical-negligence claim must fail 
because “growth and metastasis of cancer are not compensable physical injuries 
in Ohio.”  The trial court granted summary judgment in favor of the appellants 
and against all claims for relief in Loudin’s complaint. 
{¶ 9} The Ninth District Court of Appeals reversed, holding that the 
growth and metastasis of cancer is a compensable physical injury and that 
Loudin’s medical-negligence claim should have survived summary judgment.  
The appellate court pointed out that Loudin had not pleaded a separate cause of 
action for the negligent infliction of emotional distress.  However, because neither 
party claimed that the trial court should not have addressed the issue of negligent 
infliction of emotional distress, the appellate court went on to analyze that issue 
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on appeal.  After a discussion of the history of claims for the negligent infliction 
of emotional distress, the appellate court focused on this court’s explanation in 
Binns v. Fredendall (1987), 32 Ohio St.3d 244, 513 N.E.2d 278, that a negligence 
claim involving a physical injury invokes the traditional rules of recovery, which 
consider emotional distress as a part of damages.  The Ninth District held that 
Loudin’s fear of recurrence of cancer was a type of emotional injury for which 
Loudin could seek recovery. 
{¶ 10} The Ninth District concluded that the trial court’s analysis of 
negligent infliction of emotional distress was not correct and ruled that Loudin’s 
claims for medical malpractice, and her related claims for respondeat superior and 
negligent supervision, should have survived summary judgment.  The Ninth 
District affirmed the trial court’s decision regarding certain evidentiary issues, 
reversed the remainder of the decision, and remanded the cause to the trial court 
for further proceedings. 
{¶ 11} The cause is before this court upon the allowance of a 
discretionary appeal. 
Analysis 
Medical Negligence: Physical Injury 
{¶ 12} The issue before this court is whether the evidence submitted by 
Loudin in support of her claims for medical negligence and resulting damages 
was sufficient to defeat the appellants’ motion for summary judgment. 
{¶ 13} As with negligence claims in general, liability based on the alleged 
negligence of a medical professional requires proof of (1) a duty running from the 
defendant to the plaintiff, (2) the defendant’s breach of that duty, (3) damages 
sustained by the plaintiff, and (4) proximate causation of the damages by the 
defendant’s breach of duty.  Schirmer v. Mt. Auburn Obstetrics & Gynecologic 
Assoc., Inc., 108 Ohio St.3d 494, 2006-Ohio-942, 844 N.E.2d 1160, at ¶ 17, citing 
Hester v. Dwivedi (2000), 89 Ohio St.3d 575, 578, 733 N.E.2d 1161. 
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{¶ 14} A physician who undertakes a physician-patient relationship has 
the duty to exercise reasonable care in diagnosing the patient’s illness and 
prescribing appropriate treatment.  Berdyck v. Shinde (1993), 66 Ohio St.3d 573, 
583, 613 N.E.2d 1014; Tracy v. Merrell Dow Pharmaceuticals, Inc. (1991), 58 
Ohio St.3d 147, 150, 569 N.E.2d 875.  A medical professional’s failure to detect a 
condition may result in liability if the failure to detect is proven to be a proximate 
cause of a patient’s injury.  Berdyck at 584.  “Diagnosis must be regarded as 
important as is the treatment to be administered, for faulty diagnosis may result in 
treatment which is not only not correctional and curative, but is positively harmful 
in character.”  Willett v. Rowekamp (1938), 134 Ohio St. 285, 289, 12 O.O. 91, 16 
N.E.2d 457.  Although a medical professional is not a warrantor of a positive 
result or cure, a negligent act or omission that “prolongs [a patient’s] illness, 
increases his suffering, or, in short, makes his condition worse than it would have 
been if due skill and care had been used, would, in a legal sense, constitute 
injury.”  Craig v. Chambers (1867), 17 Ohio St. 253, 261, abrogated in part on 
other grounds as recognized in Cooper v. Sisters of Charity of Cincinnati, Inc. 
(1971), 27 Ohio St.2d 242, 250, 56 O.O.2d 146, 272 N.E.2d 97. 
{¶ 15} The appellants concede that Loudin adequately established duty 
and breach for purposes of summary judgment by presenting expert testimony 
that the appellants’ failure to detect her cancer in 2003 was a deviation from the 
applicable standard of care.  They focus their argument on the element of 
damages, and contend that Loudin provided no evidence that the appellants’ 
failure to timely diagnose her cancer proximately caused her any physical injury.  
They agree with the trial court’s conclusion that “growth and metastasis of cancer 
are not compensable physical injuries in Ohio,” and they point out that Loudin 
was not cognizant of the growth of her tumor from 2003 to 2004 and assert that 
the course of treatment for her cancer would have been no less intensive had it 
been detected in 2003.  These arguments are not well taken. 
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{¶ 16} First, the appellants’ contention that a plaintiff must physically 
perceive the cancer’s progression in order for it to be a compensable injury is 
unfounded.  The law recognizes that injuries in medical-malpractice cases may go 
undetected for a long time, as evidenced by the tolling of the statute of limitations 
for medical-negligence claims until the plaintiff is or should be aware of the 
injury.  R.C. 2305.113(D).  There is no requirement in Ohio that a physical injury 
in a traditional negligence case cause pain or otherwise manifest itself so that the 
plaintiff is aware of its presence and deleterious effect at all times. 
{¶ 17} Second, Loudin presented expert testimony that she would not 
have undergone an identical course of treatment had the cancer been detected in 
2003.  Loudin presented expert testimony stating that chemotherapy is not 
administered when the lymph nodes test negative for cancer.  Loudin presented 
further expert testimony that her lymph nodes would have been negative for 
cancer in 2003.  Thus, according to her experts, she would not have had to 
undergo eight rounds of chemotherapy but for the appellants’ failure to timely 
diagnose her cancer. 
{¶ 18} Third, the growth and metastasis of cancer is a cognizable physical 
injury.  Loudin presented expert testimony that cancer is a progressive disease and 
that the longer it is able to progress, the more it is able to compromise additional 
areas of the body and increase the number of cancer cells in the body.  Whether 
the cancer is left undiagnosed to advance to the point of necessitating the removal 
of an organ, a limb, a breast, or a larger lump, the destruction of additional 
healthy cells and increased number of cancer cells are physical injuries, not mere 
physical changes.2   
                                                 
2 See Tomcik v. Ohio Dept. of Rehab. & Corr. (1991), 62 Ohio Misc.2d 324, 330-331, 598 N.E.2d 
900 (growth of breast cancer, requiring a mastectomy instead of a lumpectomy, constitutes injury); 
Moskovitz v. Mt. Sinai Med. Ctr. (1994), 69 Ohio St.3d 638, 641, 647, 635 N.E.2d 331 (facts of 
case show that defendants had been found negligent for failing to timely diagnose and treat cancer 
before it had metastasized, leading to amputation and death).  See also Alexander v. Scheid 
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{¶ 19} Although tumor enlargement and involvement of the lymph nodes 
might not require radically different treatment, a plaintiff need only show some 
slight injury for the question of damages to go to the jury.  In Schultz v. Barberton 
Glass Co. (1983), 4 Ohio St.3d 131, 134, 4 OBR 376, 447 N.E.2d 109, fn. 3, 
while comparing negligent-infliction-of-emotional-distress claims with personal-
injury claims, this court explained: 
{¶ 20} “Courts have allowed recovery for emotional distress accompanied 
by the slightest injury.  ‘When there is evidence of any injury, no matter how 
slight, the mental anguish suffered by plaintiff becomes an important element in 
estimating the damages sustained.’  Clark Restaurant Co. v. Rau (1931), 41 Ohio 
App. 23, 26, 179 N.E. 196 [31 O.O. 576].  In Wolfe v. Great A & P Tea Co. 
(1944), 143 Ohio St. 643, 56 N.E.2d 230 [28 O.O. 520], the plaintiff was allowed 
to recover for mental suffering, after eating food contaminated with worms, if any 
physical injury was proven.  See also Ward Baking Co. v. Trizzino (1928), 27 
Ohio App. 475, 161 N.E. 557.” 
{¶ 21} When the evidence is viewed in a light most favorable to Loudin, 
she has raised a genuine issue of material fact as to whether she would have 
sustained physical injuries greater than those that existed in 2003 but for the 
appellants’ negligence.  Specifically, but for the failure to timely diagnose 
Loudin’s cancer, would her tumor have grown from one to two centimeters, 
would her cancer have spread to her lymph nodes and advanced from Stage I to 
Stage IIA, and would she have had to undergo chemotherapy?  The Ninth District 
correctly reversed the trial court’s summary-judgment decision on Loudin’s 
medical-negligence claim. 
Emotional-Distress Damages 
                                                                                                                                     
(Ind.2000), 726 N.E.2d 272, 284 (cancer growth and destruction of healthy tissue constitute 
injury); Evers v. Dollinger (N.J.1984), 95 N.J. 399, 406 (growth of tumor constitutes physical 
injury); Cloys v. Turbin (Tex.Civ.App.1980), 608 S.W.2d 697, 701 (any growth of a cancerous 
tumor constitutes physical injury). 
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and the Negligent Infliction of Emotional Distress 
{¶ 22} Most, if not all, of the appellants’ argument in this appeal is 
predicated upon the assumption that Loudin did not present evidence indicating 
that she sustained physical injuries as a result of the appellants’ negligence.  
Based on this assumption, the appellants assert that Loudin’s complaint raised a 
cause of action solely for the negligent infliction of emotional distress and that the 
Ninth District impermissibly created a new subspecies of the cause of action in 
order to allow Loudin’s complaint to survive summary judgment.  Loudin 
presented a genuine issue of material fact as to whether she sustained physical 
injuries as a result of the appellants’ negligence, and her complaint did not raise a 
separate cause of action for the negligent infliction of emotional distress; 
therefore appellants’ assertion is without merit. 
{¶ 23} We hold that the inclusion of damages for emotional distress in a 
complaint alleging negligence does not automatically transform the claim into one 
alleging the negligent infliction of emotional distress, nor does it automatically 
create a cause of action separate and distinct from the negligence claim. 
{¶ 24} We conclude that Loudin included a claim for damages for 
emotional distress within the context of her medical-negligence claim and that she 
did not plead a separate cause of action for the negligent infliction of emotional 
distress.  Thus, there was no negligent-infliction-of-emotional-distress claim for 
either the trial court or the appellate court to accept or reject and their discussions 
of such a claim were unnecessary. 
Conclusion 
{¶ 25} Viewing the evidence presented to the trial court in a light most 
favorable to Loudin, we hold that genuine issues of material fact exist as to 
whether the appellants’ delayed diagnosis deviated from the required standard of 
care, proximately causing physical and emotional injuries.  Therefore, we affirm 
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the judgment of the court of appeals and remand the matter to the trial court for 
further proceedings. 3 
Judgment affirmed. 
 
O’CONNOR, C.J., and PFEIFER, LUNDBERG STRATTON, LANZINGER, and 
CUPP, JJ., concur. 
 
O’DONNELL, J., concurs separately. 
__________________ 
O’DONNELL, J., concurring. 
{¶ 26} I concur in the majority’s decision that emotional distress resulting 
from a physical injury caused by an act of medical negligence is compensable but 
does not give rise to an independent cause of action on the theory of a separate 
tort.  However, I write separately to emphasize that our holding today does not 
represent a departure from the current state of the law regarding the recovery of 
damages for emotional distress. 
{¶ 27} Recovery for emotional distress has evolved over the past century.  
In Miller v. Baltimore & Ohio S.W. RR. Co. (1908), 78 Ohio St. 309, 85 N.E. 499, 
paragraph three of the syllabus, this court held that “[n]o liability exists for acts of 
negligence causing mere fright or shock, unaccompanied by contemporaneous 
physical injury, even though subsequent illness results, where the negligent acts 
complained of, are neither willful nor malicious.” 
{¶ 28} However, in Schultz v. Barberton Glass Co. (1983), 4 Ohio St.3d 
131, 4 OBR 376, 447 N.E.2d 109, this court overruled the “impact rule” set forth 
in Miller, holding that “[a] cause of action may be stated for the negligent 
infliction of serious emotional distress without a contemporaneous physical 
injury.” 
                                                 
3 The validity of Loudin’s respondeat superior and negligent-supervision claims, as well as the 
trial court’s evidentiary ruling, are not before this court. 
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{¶ 29} We reinforced our holding in Schultz in Paugh v. Hanks (1983), 6 
Ohio St.3d 72, 6 OBR 114, 451 N.E.2d 759, holding that “[a] cause of action may 
be stated for the negligent infliction of serious emotional distress without the 
manifestation of a resulting physical injury.  Proof of a resulting physical injury is 
admissible as evidence of the degree of emotional distress suffered.”  Id. at 
paragraph two of the syllabus.  Paugh described serious emotional distress as an 
“emotional injury which is both severe and debilitating” and “may be found 
where a reasonable person, normally constituted, would be unable to cope 
adequately with the mental distress engendered by the circumstances of the case.”  
Id. at paragraph 3a of the syllabus. 
{¶ 30} Nonetheless, in Binns v. Fredendall (1987), 32 Ohio St.3d 244, 
513 N.E.2d 278, we distinguished Paugh, holding that “[n]egligently inflicted 
emotional and psychiatric injury sustained by a plaintiff who also suffers 
contemporaneous physical injury in a motor vehicle accident need not be severe 
and debilitating to be compensable.”  Id. at paragraph one of the syllabus.  Thus, 
Binns reaffirmed our prior understanding that “[r]ecovery for negligently inflicted 
emotional and psychiatric injuries accompanied by contemporaneous physical 
injury may include damages for mental anguish, emotional distress, anxiety, grief 
or loss of enjoyment of life caused by the death or injury of another, provided the 
plaintiff is directly involved and contemporaneously injured in the same motor 
vehicle and accident with the deceased or other injured person.”  Id. at paragraph 
three of the syllabus. 
{¶ 31} Accordingly, our case law already establishes that a plaintiff who 
suffers a physical injury may recover for emotional distress, regardless of whether 
the emotional injuries are severe and debilitating.  Id. at paragraphs one, two, and 
three of the syllabus. 
{¶ 32} The majority affirms the holding by the court of appeals that a 
delayed diagnosis of cancer can cause an attendant physical injury for which a 
January Term, 2011 
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plaintiff may seek recovery for emotional distress as an element of damages.  And 
as the majority opinion points out, that holding is supported by authority from 
other jurisdictions.  Majority opinion at ¶ 18, fn. 2; see also Boryla v. Pash 
(Colo.1998), 960 P.2d 123; Bond v. Ivanjack (App.D.C.1999), 740 A.2d 968. 
{¶ 33} Accordingly, I concur in the judgment affirming the court of 
appeals on the basis that Lonna Loudin has raised a genuine issue of fact as to 
whether she sustained a physical injury as a result of a delayed diagnosis of breast 
cancer.  Because this case involves emotional distress stemming from a physical 
injury, Binns controls.  Thus, if Loudin proves at trial that appellants committed 
professional negligence that resulted in a physical injury that caused her 
emotional distress, then pursuant to Binns, she may recover damages for resultant 
emotional distress. 
{¶ 34} For these reasons, I agree that emotional distress resulting from a 
physical injury caused by medical negligence is compensable but does not give 
rise to an independent cause of action.  Thus, I concur in the judgment affirming 
the court of appeals. 
__________________ 
 
Scanlon & Elliott, Lawrence J. Scanlon, and Michael J. Elliott, for 
appellee. 
Roetzel & Andress, L.P.A., Douglas G. Leak, and Stacy R. Delgros, for 
appellants. 
Melissa R. Lipchak, urging affirmance on behalf of amicus curiae, Ohio 
Association for Justice. 
______________________