Title: Shpigel v. White

State: maryland

Issuer: Maryland Supreme Court

Document:

Circuit Court for Baltimore County
Case No. 03-C-97-1511
IN THE COURT OF APPEALS OF MARYLAND
No. 47
September Term, 1999
_________________________________________
MARK SHPIGEL et al.
v.
DOREEN ELIZABETH WHITE
_________________________________________
Bell, C.J.
Eldridge
Rodowsky
Raker
Wilner
Cathell
Harrell, 
JJ. 
_________________________________________
Opinion by Rodowsky, J.
________________________________________
Filed:   December 10, 1999
This appeal is taken by plaintiffs from a summary judgment for the defendant in a
personal injury action based on a motor vehicle tort.  The appeal arises out of an
unsuccessful effort to prove causation and damages through medical records and bills
without live witness sponsorship or amplification.
The plaintiffs-appellants are Mark Shpigel (Shpigel) and his children, Benjamin and
Daniela, who were respectively five and four years of age on May 21, 1996, the date of the
subject accident.  Shpigel owns and operates a 1991 Chevrolet taxicab.  The accident
occurred at the intersection of Painters Mill and Reisterstown Roads in Baltimore County
at approximately 8:45 a.m. while Shpigel was driving Benjamin and Daniela in his cab to
daycare.  Shpigel was in the merge lane from Painters Mill Road for traffic seeking to
proceed in a southerly direction on Reisterstown Road.  Unable to merge, he had come to a
full stop when a vehicle operated by the defendant-appellee, Doreen Elizabeth White
(White), made contact with the rear of Shpigel's cab.  There is no claim for property damage
to Shpigel's taxicab in the record before us, and none of the plaintiffs, all of whom were
wearing their seatbelts, suffered any impact against any portion of the interior of the cab. 
The plaintiffs were transported by ambulance to Northwest Hospital Center in
Randallstown where they were examined in the emergency room by a Dr. Matheus.  Each
plaintiff was discharged that morning, and, on discharge, computer generated discharge
instructions were furnished for each plaintiff between 11:20 a.m. and 11:32 a.m.  These
discharge instructions were signed by a member of the emergency room staff.  Shpigel's set
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of instructions estimated that his complaints would subside in three days.  His hospital bill
was $146.30, and those of the children were $51.04, each.  
On the day immediately following the accident Shpigel presented at the offices of Drs.
Braeger, Gaber and Associates, P.A. (the P.A.).  Following the initial examination there were
four follow-up visits.  The P.A. also administered physical therapy on eight occasions
between May 24 and July 25, 1996.  Records generated by the P.A. which Shpigel sought
to introduce consisted of a bill totaling $867, notes of office visits, and three "disability
certificates" that collectively state that Shpigel was "totally incapacitated" from May 22
through June 14 and that he had "recovered sufficiently to be able to return to regular work
duties on June 17, 1996."
Also on the day immediately following the accident Benjamin and Daniela were
examined by a pediatrician, Dr. Allen Stambler, who found nothing wrong with either child.
Dr. Stambler billed $450 per child, a figure that includes $75 per child for the preparation
of reports to plaintiff's counsel.  On May 28, 1996, William D. Petok, Ph.D. conducted a
"diagnostic interview exam" of Benjamin and Daniela, followed by four "family
psychotherapy" sessions, the last of which was on August 19, 1996.  Dr. Petok billed $475.
The record does not contain any written report from him.
The instant action was filed on February 13, 1997, and the summary judgment from
which this appeal is taken was entered on November 30, 1998, the day on which trial was
scheduled.  During discovery the plaintiffs furnished copies of the reports of the P.A. and of
Dr. Stambler to White by attaching them to answers to interrogatories.  On February 12,
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1998, the plaintiffs also furnished copies of all of the bills and reports in issue here in
response to the defendant's request for production of documents.  
In June 1998 the plaintiffs sought voluntarily to dismiss this action in order to refile
in the District Court of Maryland.  White opposed that dismissal on the ground that she was
entitled to a jury trial, and the circuit court refused leave to dismiss.  See Maryland Rule
2-506(b).  The trial date of November 30, 1998 was set on June 11, 1998.  
On October 21, the plaintiffs served a request for admissions on White to which the
medical reports and bills were attached.  The plaintiffs sought an admission that the
documents were business records and that the amounts charged were fair, reasonable, and
necessary.  White denied the request for admissions.  The plaintiffs also served the following
notice on White on October 21:
"Plaintiffs ... hereby give notice of their intent to place in evidence at
the trial of this case pursuant to Maryland Rules including, but not limited to,
Rules 5-803(b)(3), (4) and (6), copies of the documents designated
EXHIBITS A-T appended to the Plaintiffs' Request For Admissions previously
served on Defendant's counsel, authenticated by a custodian of records."
Exhibits A through T include all of the medical records, reports, and bills in issue here.
On the morning of trial the court and counsel met in chambers.  Although that meeting
is unrecorded, it seems to have considered, in effect, a motion in limine by White.  It is clear
that the discussion focused on the plaintiffs' intent to proceed without producing any live
expert medical testimony and on White's objection that the records were not admissible, or
if admissible, legally insufficient.  At the conclusion of the discussion, proceedings were
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Maryland Rule 5-803(b)(6) reads:
1
"The following are not excluded by the hearsay rule, even though the
(continued...)
conducted in open court for the purpose of giving the plaintiffs the opportunity to make by
proffer a record for appeal.
Counsel for the plaintiffs explained that the clients could not afford to pay the fees
charged by the experts to testify in court.  After describing the way in which the accident
happened, counsel proffered that Shpigel would testify that, following the impact, he "felt
an immediate pain in his neck landing on the right side.  The children were also shaken on
the impact and were frightened and crying."  Shpigel further would testify "that the pain in
his neck worsened over the next several hours, he developed headaches, general stiffness and
aching, [and] had difficulty sleeping because of the pain."  In addition, Shpigel would have
testified that he lost income while he continued to carry certain business expenses during the
period he was disabled from working.  The children were examined by Dr. Stambler, it was
proffered, because the instructions from the hospital were that "they should be followed up
on by their pediatrician."  Dr. Petok was consulted because "the children became extremely
fearful about riding in a vehicle.  Their parents' efforts to reassure them ha[d] very little
effect.  They also had sleep disturbances ...."
The plaintiffs then tendered the records and bills, with accompanying affidavits by
the custodians of those records.  The affidavits stated as fact all of the elements required for
admissibility of a business record under Maryland Rule 5-803(b)(6).   With respect to the
1
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(...continued)
1
declarant is available as a witness:
....
"(b)
Other exceptions.  ...
....
"(6)
Records of regularly conducted business activity.  A
memorandum, report, record, or data compilation of acts, events, conditions,
opinions, or diagnoses if (A) it was made at or near the time of the act, event,
or condition, or the rendition of the diagnosis, (B) it was made by a person
with knowledge or from information transmitted by a person with knowledge,
(C) it was made and kept in the course of a regularly conducted business
activity, and (D) the regular practice of that business was to make and keep the
memorandum, report, record, or data compilation.  A record of this kind may
be excluded if the source of information or the method or circumstances of the
preparation of the record indicate that the information in the record lacks
trustworthiness.  In this paragraph, 'business' includes business, institution,
association, profession, occupation, and calling of every kind, whether or not
conducted for profit."
bills for services, a lay custodian for Northwest Hospital Center, a lay custodian for the P.A.,
and Drs. Stambler and Petok respectively made affidavit that their bills were fair and
reasonable and that the services were incurred as a direct result of the automobile accident
of May 21, 1996.  
White argued, inter alia, "that Mr. Shpigel himself has had multiple prior accidents
and there is documentation indicating that there are residuals.  It's our position that we are
entitled to cross-examine those individuals on the fairness, reasonableness of treatment,
billing and causal connection."  
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From a procedural standpoint, the circuit court treated the issue before it as one raised
by a motion for summary judgment in favor of the defendant.  The court granted the motion,
stating that it was "this court's view that in a case such as this, the issue of causation requires
an expert opinion."  The court then explained why "as a practical matter" the records would
not be admitted "in a case such as this," saying:  
"The defense alleges that these injuries are not caused by this accident.
That the plaintiff's condition is not as a result of the occurrence that happened
on May 21st involving Miss White, that it's related to some other occurrence
or other occurrences.  That the treatment was not reasonable.  That the medical
expenses the plaintiff incurred were not reasonable.  And the defense wants
the opportunity to cross-examine and to see if some expert will say that they
are reasonable, will say that it's causally connected in court.  Without such
testimony put on by the plaintiff that, in fact, there is a causal connection
between the negligence the breach of the duty and the damages then the jury
cannot hear the case."
After referring to Maryland Code (1974, 1998 Repl. Vol.), § 10-104 of the Courts and
Judicial Proceedings Article (CJ), dealing principally with the admissibility in the District
Court of Maryland of writings or records of health care providers and discussed, infra, the
court ruled that "the types of records sought to be introduced in this case are not admissible
in circuit court."
The plaintiffs appealed to the Court of Special Appeals, and this Court issued the writ
of certiorari on its own motion in order to address the fundamental issues presented.
I
We shall first address whether, and to what extent, the plaintiffs were able to
overcome a hearsay objection to their attempted introduction of the records as business
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records under Rule 5-803(b)(6).  To lay the authenticity foundation for admission under that
hearsay exception, the plaintiffs sought to use Rule 5-902(a)(11) which reads as follows:
"(a)
Generally.  Except as otherwise provided by statute, extrinsic
evidence of authenticity as a condition precedent to admissibility is not
required with respect to the following:
....
"(11) Certified records of regularly conducted business activity.  The
original or a duplicate of a record of regularly conducted business activity,
within the scope of Rule 5-803(b)(6), which the custodian or another qualified
individual certifies (A) was made, at or near the time of the occurrence of the
matters set forth, by (or from information transmitted by) a person with
knowledge of those matters, (B) is made and kept in the course of the regularly
conducted business activity, and (C) was made and kept by the regularly
conducted business activity as a regular practice, unless the sources of
information or the method or circumstances of preparation indicate lack of
trustworthiness; but a record so certified is not self-authenticating under this
subsection unless the proponent makes an intention to offer it known to the
adverse party and makes it available for inspection sufficiently in advance of
its offer in evidence to provide the adverse party with a fair opportunity to
challenge it."
The notice sent by the plaintiffs on or about October 21, 1998, arguably complied
with the requirement of Rule 5-902(a)(11) for notice of intent to offer the documents as self-
authenticating records "sufficiently in advance of [their] offer in evidence to provide [White]
with a fair opportunity to challenge [them]."  The records had been furnished to White in the
preceding February in the plaintiffs' response to White's request for the production of
documents.  In the Rule 5-902(a)(11) certifications the custodians of the proffered records
made oath as to the three factual elements, (A), (B), and (C), required by the Rule.  The
circuit court did not address the adequacy of the notice to invoke Rule 5-902(a)(11), although
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White argued that the notice was inadequate.  The circuit court, in effect, exercised its
discretion in not granting summary judgment on that ground, and we do not ordinarily
undertake to sustain a summary judgment by ruling on a ground not ruled upon by the circuit
court.  See Three Garden Village Ltd. Partnership v. United States Fidelity & Guar. Co., 318
Md. 98, 107-08, 567 A.2d 85, 89 (1989).  
In rejecting the proffered documents the circuit court in part relied on CJ § 10-104.
That statute, inter alia, applies to a claim for "[d]amages for personal injury."  § 10-
104(b)(1)(i).  Its application is limited to a proceeding in the District Court of Maryland, or
to certain proceedings in a circuit court under circumstances which are not applicable here.
§ 10-104(b)(2).  Under the statute a writing or record of a health care provider, which is
otherwise admissible, "is admissible without the support of the testimony of a health care
provider as the maker or the custodian of the writing or record to prove the existence of a
medical, dental or health condition, the opinion, and the necessity and the providing of health
care."  § 10-104(d).  Further, under § 10-104(e)
"[a] written statement or bill for health care expenses is admissible without the
support of the testimony of a health care provider as the maker or the
custodian of the statement or bill to prove the amount, fairness, and
reasonableness of the charges for the services or materials provided."
In order to utilize this statute, the proponent of the evidence must give notice to all
other parties, at least sixty days before the beginning of the trial of that party's intent "to
introduce the writing or record without the support of a health care provider's testimony" and
furnish a copy of the writing or record to all other parties.  § 10-104(c)(1).  
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Originally § 10-104 applied only to District Court cases.  See Chapter 554 of the Acts
2
of 1996.  House Bill 423 of the 1997 General Assembly session would have applied § 10-104
to both circuit court and District Court cases, but the bill was amended in the course of
passage to apply only to certain proceedings in circuit court that are not applicable here.  See
Chapter 443 of the Acts of 1997.
Section 10-104 does not restrict the scope and operation in a circuit court of
Maryland Rule 5-902(a)(11).  Rule 5-902 became effective July 1, 1994, Michie's Annotated
Code of Maryland, 1 Md. Rules at 663 (1999), while CJ § 10-104 was enacted by Chapter
554 of the Acts of 1996 and has been amended subsequently.  Although the statute is later
in time, it would violate a well recognized rule of statutory construction to construe the
statute as impliedly repealing the rule when the latter is relied upon to introduce the business
records of health care providers in an action initially filed in the circuit court.   More
2
important, § 10-104 clearly is intended to liberalize the admissibility of the business records
of health care providers far beyond the self-authentication provisions of Rule 5-902.  Under
the statute, and unlike the rule, no certification of the custodian is required to establish
authenticity.  Further, but without undertaking exhaustively to describe possible differences,
the statute eliminates any requirement that the proponent of the evidence prove the fairness
and reasonableness of the charges for the health care rendered.  
Accordingly, to the extent that the circuit court indicated that a statute, such as CJ §
10-104, was needed in order to make any of the proffered records admissible in a circuit
court, we disagree. 
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II
"[E]ven though a particular hospital record is not barred from evidence as hearsay,
it may be that some or all of its contents are open to objection on other grounds."  Dietz v.
Moore, 277 Md. 1, 7, 351 A.2d 428, 433 (1976).  Consequently, we must examine the
classes of records proffered by the plaintiffs from the standpoint of whether the records
themselves established admissibility.  
A.  Medical Bills
The plaintiffs' purpose in offering the medical bills in evidence was to prove special
damages.  In order for the amount paid or incurred for medical care to be admissible as
evidence of special damages, there ordinarily must be evidence that the amounts are fair and
reasonable.
"Evidence of the amount or payment of medical bills does not establish the reasonable
value of the services for which the bills were rendered or justify recovery therefor."  Kujawa
v. Baltimore Transit Co., 224 Md. 195, 208, 167 A.2d 96, 102 (1961).  In Kujawa we
affirmed a trial court's ruling that the amount of medical bills incurred by a mother and her
son could not be established through the testimony of the mother.  We indicated, however,
that the personal appearance of the billing doctors was not required.  The only requirement
was that the plaintiffs should "'have evidence'" that the charges were reasonable.  Id. (quoting
trial court's ruling).  See also Brooks v. Fairman, 253 Md. 471, 476, 252 A.2d 865, 868
(1968) (absent evidence of the reasonableness of charges for medical services, an error
affecting the verdict in that action, case remanded for a new trial); Metropolitan Auto Sales
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Corp. v. Koneski, 252 Md. 145, 154, 249 A.2d 141, 146 (1969) (absent evidence, inter alia,
of the reasonableness of hospital charges, judgment reduced and, as reduced, affirmed); In
re. Gloria T., 73 Md. App. 28, 33-34, 532 A.2d 1095, 1097-98 (1987) (medical bills are not
admissible to support restitution award in juvenile proceeding without some evidence of
reasonableness), cert. denied, 311 Md. 718, 537 A.2d 272 (1988); Thomas v. Owens, 28 Md.
App. 442, 445, 346 A.2d 662, 664 (1975) ("[B]efore a medical bill can be admitted to prove
the reasonableness of the amount charged, there must be other evidence that the charge set
forth in the bill was reasonable.").
Professor McLain has pointed out that, although authentication as a business record
can be accomplished under Rule 5-902(a)(11) without a live witness, "a live witness still will
be needed if ... the business record does not establish all the facts needed to be proved, such
as that the proved medical bills were 'reasonable and customary.'"  L. McLain, Self-
Authentication of Certified Copies of Business Records, 24 U. Balt. L. Rev. 27, 75 (1994).
See also P.W. Grimm, New Rule Covers Authentication of Business Records, Vol. 10, No.
2, The Maryland Litigator 1, 5 (Dec. 1994) ("The mere fact that these records are admitted
into evidence without a testimonial sponsor would not establish that the charges for the
services reflected in the bills are reasonable and customary, nor that the treatment itself was
appropriate.").
Inclusion in the affidavits of certain of the custodians of the records proffered in the
instant matter of statements that the charges were reasonable did not make the medical bills
admissible.  On that aspect of admissibility required by our cases, the fact to be proved is the
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reasonableness of the bill, but the witness to that fact is not present and subject to cross-
examination.  Accordingly, the circuit court did not err in excluding from its consideration
on summary judgment the medical bills proffered by the plaintiffs.
B.  The Physicians' Records
In the P.A.'s consultation note dictated on May 29, 1996, based on an examination of
May 22, the "clinical impression" as of the date of that examination was that Shpigel
"sustained acute musculoligamentous strain injury of the supporting structures of the cervical
spine."  The "medical history" segment of the initial consultation note advises that Shpigel
"was involved in a motor vehicle accident one year ago in which he injured his neck but from
which he recovered without sequelae" and that "[h]e had been followed through this office
for that injury as well."  Shpigel's purpose in proffering the P.A.'s records concerning his
examinations, his visits for physical therapy, and the disability certificates is to prove that
he was totally disabled from May 22 through June 17, 1996, with resulting  economic and
non-economic damages.  
In order to fall within the Rule 5-803(b)(6) exception to the hearsay rule the evidence
must be trustworthy.   Further, relevant "evidence may be excluded if its probative value is
substantially outweighed by the danger of ... confusion of the issues, or misleading the jury."
Rule 5-403.  Here, the causal connection between the accident of May 21, 1996, and the
damages claimed by Shpigel presents a somewhat complicated medical question on which
expert testimony is required in order to support a finding that the accident of May 21, 1996,
caused a total disability.
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The seminal case in this state is Wilhelm v. State Traffic Safety Commission, 230 Md.
91, 185 A.2d 715 (1962).  There we held that expert testimony was required in order to
establish a causal nexus between a motor vehicle collision and "emotional disturbances in
[the plaintiff] sufficient to evoke, subconsciously, grossly exaggerated symptoms."  Id. at
101, 185 A.2d at 719.  Expert testimony was also required to establish a nexus "between the
accident and abdominal and back pains associated with the [plaintiff's] menses."  Id.  No
expert testimony, however, was required in order to prove the nexus between the accident
and a loss of pigmentation on the plaintiff's forehead at the site where her head struck a sun
visor in the accident and where she had a bruise for some three or four months.  Id. at 103,
185 A.2d at 721.
Maryland appellate cases on this issue have recently been reviewed for the Court of
Special Appeals by Judge Thieme in Hunt v. Mercy Medical Center, 121 Md. App. 516,
538-42, 710 A.2d 362, 373-75 (1998), and by Judge Moylan in S.B. Thomas, Inc. v.
Thompson, 114 Md. App. 357, 376-81, 689 A.2d 1301, 1310-13 (1997).  Although
recognizing that these cases are fact specific the court in S.B. Thomas undertook a
distillation, saying:
"A genuine jury issue as to the causal relationship between an earlier injury
and a subsequent trauma may sometimes be generated, even in the absence of
expert [medical] testimony, when some combination of the following
circumstances is present:  1) a very close temporal relationship between the
initial injury and the onset of the trauma; 2) the manifestation of the trauma in
precisely the same part of the body that received the impact of the initial
injury; 3) as in Schweitzer v. Showell, [19 Md. App. 537, 313 A.2d 97 (1974),]
some medical testimony, albeit falling short of a certain diagnosis; and 4) an
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obvious cause-and-effect relationship that is within the common knowledge
of laymen."
Id. at 381-82, 689 A.2d at 1313.  In this case there is no "obvious cause-and-effect
relationship" between the accident and the claimed total disability "that is within the common
knowledge of laymen."
Here, the issue is whether the records of the P.A., in and of themselves, are admissible
to supply the necessary medical opinion.  The same factors that underlie the holdings on the
need for expert medical testimony on causation are also relevant to whether that expert
testimony is to be presented through a live witness or through a business record.  In this case
the records of the P.A. reflect that Shpigel previously suffered a neck injury, and White
contests the opinion, expressed in the records of the P.A., that there are no residual
symptoms from that prior injury.  The instant case also involves issues of the degree of force
of the trauma, and there is a conflict between the P.A.'s opinion of a total disability of several
weeks duration and the prognosis of three days discomfort made in the hospital discharge
instructions.
Although Maryland Rule 5-803(6) is not verbatim Fed. R. Evid. 803(6), the changes
in the former from the latter "are intended to be nonsubstantive."  L. McLain, Maryland
Rules of Evidence, at 245 (1994).  The editors of 5 Weinstein's Federal Evidence
§ 803.11[7][a], at 803-76 through 803-77 (2d ed. 1999), in addressing the type of issue now
before us, state that "[i]f the expert is available and the diagnostic opinion is of a kind
competent physicians may disagree upon, the judge has discretion to require the expert to
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testify to insure trustworthiness through cross-examination, particularly if the medical issue
is crucial."   (Footnote omitted).  
In Owens-Illinois, Inc. v. Armstrong, 326 Md. 107, 604 A.2d 47, cert. denied, 506
U.S. 871, 113 S. Ct. 204, 121 L. Ed. 2d 145 (1992), this Court described the factors that
could lead to a determination that a business record is untrustworthy.  We said:
"The factors that can be utilized by a trial judge in determining whether
a business record or a portion of a business record should be excluded for lack
of trustworthiness may include such factors as:  1) the purpose for which the
record was prepared and any possible motive to falsity including whether the
record's use in prospective litigation was a motive for its preparation; 2) how
routine or non-routine the record is and how much reliance the business places
on the record for business purposes; and 3) where, as in the instant case, the
record contains opinions and conclusions--how valid, speculative, or
conjectural the opinions or conclusions are, as well as the need for
interpretation or cross-examination to prevent misleading or confusing the trier
of fact."
Id. at 115, 604 A.2d at 50-51 (citations omitted).
Somewhat analogous to the instant matter is Chadderton v. M.A. Bongivonni, Inc.,
101 Md. App. 472, 647 A.2d 137 (1994).  Chadderton was a workers' compensation case in
which the insurer and the Subsequent Injury Fund succeeded in placing in evidence in the
circuit court copies of the reports rendered to them by the physicians to whom they had
referred the claimant for the purpose of obtaining an opinion on the nature and extent of
disability.  Closely following the analysis in Yates v. Bair Transport, Inc., 249 F. Supp. 681
(S.D.N.Y. 1965), the Court of Special Appeals held that the reports were inadmissible.
Yates was a motor vehicle accident case involving a plaintiff who had previously
made a workers' compensation claim.  The plaintiff sought a pretrial ruling on the
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admissibility of medical reports rendered by his treating physicians in the then pending
accident case and by physicians who had examined him for the insurer in the workers'
compensation case and for the insurer of the defendant in the motor vehicle accident case.
Id. at 689.  There was a stipulation that the reports were authenticate, and the court
concluded that they were regularly maintained business records.  The Yates court then
addressed the concern noted in Palmer v. Hoffman, 318 U.S. 109, 63 S. Ct. 477, 87 L. Ed.
645 (1943), "with the likely untrustworthiness of materials prepared specifically by a
prospective litigant for courtroom use."  Yates, 249 F. Supp. at 689.  The court in Yates
looked for "an added element of trustworthiness which will counterbalance the fact that these
reports were prepared in clear anticipation of litigation."  Id. at 689-90.  That added element
of trustworthiness was found in those reports that were rendered by physicians to whom the
plaintiff had been referred by the defendant, and the Yates court ruled that it would admit
those reports.  On the other hand, the court would not admit those reports rendered by the
plaintiff's treating physicians, saying:  "No case, however, has been found or cited wherein
a plaintiff was permitted to introduce self-serving reports made by doctors of his own
choosing, in anticipation of litigation to shore up his own case."  Id. at 691 (footnote
omitted).
The Court of Special Appeals in Chadderton, applying the Yates rationale, held that
the reports rendered by physicians to whom the claimant had been referred by the workers'
compensation insurer and the Subsequent Injury Fund were not admissible when introduced
by the parties who had arranged for those reports, essentially for a lack of trustworthiness.
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Chadderton, 101 Md. App. at 483-84, 647 A.2d at 142.  Erroneously admitting the reports
was held to be prejudicial, because the plaintiff was unable to cross-examine the physicians
whose opinions were introduced in report form.  Id. at 486, 647 A.2d at 144.  Thus, although
the circuit court in Chadderton had been persuaded that the reports were admissible under
a section of the Workers' Compensation Act stating that "'the proceedings in an appeal shall
be informal and summary,'" id. at 479, 647 A.2d at 140, and although the circuit court had
found the reports to be sufficiently trustworthy, the Court of Special Appeals focused only
on the trustworthiness aspect of that ruling.  The appellate court in effect held that the circuit
court had abused its discretion in concluding that the reports were trustworthy.
Much the same problem was presented in Kelly v. HCI Heinz Construction Co., 668
N.E.2d 596 (Ill. App.), appeal denied, 675 N.E.2d 634 (Ill. 1996).  Kelly, a bricklayer, was
injured in the collapse of a scaffold on which he was working.  Under the Illinois Structural
Work Act he sued the general contractor and the company which had supplied the
scaffolding.  At trial Kelly unsuccessfully sought to introduce as business records the records
of his attending physician and the records prepared by a physician to whom the scaffolding
supplier had referred Kelly.  The appellate court sustained both exclusions.  The treating
physician's records were excluded as records prepared in anticipation of litigation and not
made in the regular course of business.  Id. at 600.  The same objection applied to the report
by the defense expert, but those records "may nevertheless be admissible against a party as
an admission."  Id.
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The Illinois court then summarized a portion of 2 J.W. Strong, McCormick on
Evidence § 293, at 281 (4th ed. 1992).  The full text of the cited portion of that commentary,
dealing with diagnostic statements in hospital records, is as follows:
"However, admissibility of all such entries is not assured.  First, where there
are indications of lack of trustworthiness, which may result from a lack of
expert qualifications or from a lack of factual support, exclusion is warranted
under the rule.  Moreover inclusion of opinions or diagnoses within the rule
only removes the bar of hearsay.  In the absence of the availability of the
expert for explanation and cross-examination, the court may conclude that the
probative value of this evidence is outweighed by the danger that the jury will
be misled or confused.  This is of particular concern if the opinion involves
difficult matters of interpretation and a central dispute in the case, such as
causation.  Under these circumstances, a court operating under the Federal
Rules, like earlier courts, is likely to be reluctant to permit a decision to be
made upon the basis of an un-cross-examined opinion and may require that the
witness be produced."
Id. (footnotes omitted).  
The Illinois appellate court held that "[t]he trial court could properly have concluded
that the opinions of [the defense expert] were important enough that they should be presented
by live testimony, rather than in the form of medical records."  Kelly, 668 N.E.2d at 600.  
In the matter now before us the factors considered by the cases and commentators
reviewed above are present.  Although the P.A. records were not so clearly prepared for
litigation as are medical reports rating a claimant for workers' compensation benefits,
nevertheless, the issuance by the P.A. of total disability certificates to Shpigel, who is self-
employed, and who was on a personal trip when the accident occurred, suggests that
litigation considerations were recognized in conjunction with the medical treatment.  Further,
the subject matter of the P.A. records are central to the litigation, the opinions contained
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therein are contested, as indeed is the necessity for the treatment, and the conflict with the
prognosis of the emergency room discharge instructions evidences that White's insistence on
the opportunity to cross-examine is not without foundation.  Consequently, we hold that the
circuit court acted within its discretion in ruling that the P.A. records would not be
admissible.  This discretion is conferred by the trustworthiness requirements of Rules
5-902(a)(11) and 5-803(b)(6), as well as by the trial judge's discretionary power conferred
by Rule 5-403 to exclude evidence if its probative value is outweighed by the danger of
misleading the jury.
The findings in Dr. Stambler's reports to plaintiffs' counsel, based on his examinations
of Benjamin and Daniela, are essentially negative.  They report that each child "was
obviously frightened, and cried immediately after the accident" and that each child "slept
well that evening, experienced no vomiting, but complained of frontal headache."  We infer
that Dr. Stambler's report was proffered in order to evidence the reasonableness or necessity
of Shpigel's engaging a psychologist to examine and treat the children. Viewed from this
light, there was no error in excluding Dr. Stambler's reports because there is no report from
the psychologist and Dr. Stambler's reports do not recommend any psychological
consultation.  
C.  The Hospital Records
The hospital records of Northwest Hospital Center concerning the emergency room
visits of Shpigel, Benjamin, and Daniela immediately following the accident are offered as
within the business records exception to the hearsay rule, and for the purposes of this appeal,
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we treat the proffered records as authenticated, as described in Part I above.  This Court has
said that "the business records exception to the rule against hearsay, under which hospital
records are included, 'properly administered ... would seem to be among the safest of the
hearsay exceptions.'"  State v. Garlick, 313 Md. 209, 216, 545 A.2d 27, 30 (1988) (quoting
Ohio v. Roberts, 448 U.S. 56, 66 n.8, 100 S. Ct. 2531, 2539 n.8, 65 L. Ed. 2d 597, 608 n.8
(1980)).   "[O]nce it is clear that the hospital record was made during 'the regular course of
business' and the recorded transactions are 'pathologically germane to treatment' the record
is admissible as an exception to the hearsay rule."  Id. at 223, 545 A.2d at 33.  "[W]e have
held in numerous cases [that] hospital records are not inadmissible as hearsay in Maryland
because they fall within the statutory business record exception."  Dietz, 277 Md. at 7, 351
A.2d at 432. 
Rule 5-803(b)(6) expressly recognizes that a "diagnosis" may be part of a business
record.  Further, in appropriate cases, this exception to the hearsay rule may apply where the
proponent of the record seeks to use it to prove a causal connection between some trauma
and a claimed physical injury.  Lee v. Housing Authority of Baltimore, 203 Md. 453, 101
A.2d 832 (1954), is illustrative.  In that case the plaintiff's decedent died from burns suffered
in a fire in the pantry area of her apartment leased by her and her husband from the
defendant.  The plaintiff sought to introduce as substantive evidence the record from the
hospital emergency room which included the statement that the patient had been admitted
"following the explosion of a gasoline water heater in a confined area."  Id. at 459, 101 A.2d
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at 834 (italics omitted).  This Court held that the quoted portion of the hospital record should
have been admitted by the trial court.  It was pathologically germane.  The Court explained:
"In the instant case we think the record of the alleged cause of the burns
to be treated was a proper part of the medical history.  The entries do not
undertake to establish the cause of the explosion, but merely relate to the
nature of the substance causing the burns, gas, and the character of the
combustion, an explosion.  It is certainly customary and proper to record the
type of accident causing the injury, and this information may have an
important bearing upon the diagnosis, as indicating what the doctors should
look for, and upon the treatment to be applied.  We think the information
recorded, from whatever source obtained, was not outside the regular course
of professional inquiry."
Id. at 460-61, 101 A.2d at 835.
Scott v. James Gibbons Co., 192 Md. 319, 64 A.2d 117 (1949), involved the use of
hospital records by the plaintiff in a fatal automobile accident case.  There this Court said:
"Of course such records are admissible, and statements therein showing the
history of the patient's physical condition are proper.  History in this
connection means the physical background as well as the present condition of
the patient.  It is proper for the record to show the patient was hurt in an
automobile accident, but the particulars of such accident, contained in a
hospital record, should be deleted and not submitted to a jury in a case like
this.  This is hearsay."
Id. at 330, 64 A.2d at 122.
In the instant matter the computer generated discharge instructions for each plaintiff
begin in part by saying, "Our doctors and staff appreciate your choosing us for your
emergency medical care needs."  The next section headed, "Motor vehicle accidents," is the
same for each plaintiff.  In part it reads:  
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Examples of the latter include Advil.  
3
"You have suffered injuries in a car crash.  Although you have been injured,
hospital care does not appear to be needed right now.  ... These minor injuries
are usually much better after 3 days."
The printouts for the two children next contain "additional instructions" and "follow up care"
sections.  Benjamin was advised to "follow up with your pediatrician if needed," and Daniela
was advised to rest and follow-up with her pediatrician.  In another section of their
instructions the children respectively were advised to call the pediatrician "as soon as
possible."
The discharge instructions for Shpigel contain additional sections headed "Muscle
strain," "neck injuries," "heat therapy," "prescriptions," and "Ibuprofen."   Under the "neck
3
injuries" section the record states:  "Your exam shows you have strained the muscles and
ligaments in your neck.  This injury is very common in car accidents."  
The circuit court found that the particular hospital records proffered in this case were
not trustworthy.  We hold that, in so finding, the court acted within its discretion.  It is
apparent from the face of the Northwest Hospital emergency room discharge instructions that
they are not traditional hospital records.  They are an aggregation of pre-programmed,
computer-generated paragraphs — in a word, they are boilerplate.  
Looking at the admissibility issue from its most fundamental aspect, the hospital may
not even have intended that the discharge instructions express an opinion whether there was
any bodily injury or any need for emergency room treatment.  The sentence, "You have
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suffered injuries in a car crash," may be simply a "plain language" way of stating the history
given by the plainitff and not a medical diagnosis that there were injuries.  Similarly, the
sentence, "Our doctors and staff appreciate your choosing us for your emergency medical
care needs " may be no more than a discrete way of saying, "Thanks for your business," and
not an opinion that emergency room treatment was reasonably necessary.  
If we assume that the statement, "[a]lthough you have been injured" is intended to be
a diagnosis, it is so general as to be of little help to a jury.  The statement that appears only
in Shpigel's discharge instructions to the effect that he has suffered a strain of the muscles
of the neck, appears to be intended as a diagnosis.  The record, however, is unclear as to who
made the assumed diagnosis.  The discharge instructions are not signed by the physician who
is identified as having examined the plaintiffs.  The person who does sign the discharge
instructions does so above a line marked "Staff Signature," but the qualifications of that
person are unknown.  Also unknown is whether the examining physician specifies which
boilerplate paragraphs are to be printed or whether the staff person decides which paragraphs
are appropriate, based on information received.  Records of a regularly conducted business
activity "may be excluded if the method or circumstances of the preparation of the record
indicate that the information in the record lacks trustworthiness."  Rule 5-803(b)(6). 
Further, without live testimony in the instant matter, the jury would be left ignorant
of how restricted the physician might be, within the computer program's menu of boilerplate
paragraphs, in matching the actual findings to the available print-outs.  For example, could
the physician have printed out specific objective findings of the examination, if that were the
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This case was argued in this Court as if the proffered documents were the sole source
4
of admissible evidence in support of the plaintiffs' claims.  The plaintiffs did not argue in the
circuit court or here that this case was the type in which medical testimony was not required
to prove some harm and an entitlement to some damages.  See Wilhelm v. State Traffic
Safety Comm'n, 230 Md. 91, 185 A.2d 715 (1962). 
case, or have printed out that the diagnosis was based entirely on subjective complaints, if
that were the case?
In this litigation the visits to the emergency room are the first steps in Shpigel's claim
of total disability and in the claim on behalf of the children for psychological harm.  Those
claims are vigorously contested, and the circuit court permissibly could conclude that
medical evidence offered to support the first steps should be subject to cross-examination.
Thus, although in many cases emergency room records, when authenticated and
pathologically germane, may be readily admitted pursuant to Rule 5-803(b)(6), under the
facts of this case the circuit court did not abuse its discretion in ruling that the discharge
instructions were not admissible.    
4
III
For all of the reasons stated above, the judgment of the Circuit Court for Baltimore
County is affirmed.
JUDGMENT OF THE CIRCUIT COURT FOR
BALTIMORE COUNTY AFFIRMED.  COSTS
TO BE PAID BY MARK SHPIGEL, ONE OF
THE APPELLANTS.
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