## In the



# U n ited S ta tes Co urt o f Ap p ea ls

F o rth eS e v e n th C ir cu it
N o. 11

- 3691 J OS HUA B ELL ER, a m inor, by h is nex t fri en d and m oth er, M elis sa W elc h, et a l., P la intif fs-A pp ella nts, v.
H EA LT H A ND H OSPI TAL C O RP . OF M AR I ON C OUN TY, I NDI ANA, d /b/a W I S HARD M EMORIAL H OS PI T AL, d /b/a W I S HARD A MBULANCE S ERVI CE, D efend a nt-A pp ellee.

A pp eal from the United S t ates Di strictC our t fo r the S outhernDi stricto f Indian a, Indian apolisDiv isi on. No . 1:0 3-cv-00 88 9-TWP-TAB

—Tanya W alt on P ratt, Judg e. A RGUED A PRI L 20, 2012

— D ECI DE D D ECE MBE R 20, 2012

Befo re M A NI ON, R OV NER, a nd W I L L I A MS, Circ uit Ju dg es . R OV NER, Cir cu i tJudg e . T h e p lain tiffs br ou gh t s u it al l eging tha t the defendant, H eal th and H ospi talCor pora ti on o f M ar i on County, Ind i ana d/b /a W i shar d M em or i al2 N o. 11

- 3691 H ospi tald/b/ a W i shar d A m bul ance S er vi ce ( “W i shar d”) viol ate d the Em er gencyM edi calTre atm ent a nd A cti ve LaborA ct ( “E M T A L A ”), 42 U
. S. C. § 1 395dd, byf ai l i ng to stab il ize M eli ssa W elch an d her m in or son, J osh ua Be ll er, du ring an em er gencym edi calsi tu ati on. The di str i ct co ur t grant ed su m m ar y j udg m en t f o r W i sh ar d, a nd the p lain tiffs ap p ea l. OnJ un e 1 4 , 2 0 0 1 , Mel i s s a Wel c h c a l l ed 9 1 1 a nd a W i shar d am bul ance was di spatched to h erhom e. W el ch w as 34 w eek s pregnant, and the param edi cs a scer tained that her w ate r b ro ke and she had a pro l apsed um bi l i cal co r d. The p aram edi cs t r i ed to r el i ev e pr es su r e o n the cord , and a fte r cons ulting w ith th e nu rse at W elch’s obs tet ri ci an’ s o ffi ce, ag re ed that W el ch needed to be tr anspor ted to the near esthos pit al

. They th en co ntacte d the S t
. F r a nc i s Be e c h Gr o v e ( “ Be e c h Gr o v e ” ) e merge ncy ro om a nd t r a ns po r t e d he r the r e . Be e c h Gr o v e di d no t ha ve a n obs te tr i cs f ac i l i ty
. Ra th ertha n de l i ve r i ngthe baby th er e, the physi ci an atBeech Gro ve exam i ned W el ch and then s ent he r i n th e W i shar d am bul ance t o St
. Fr anci s Hospit alS outh. There , J oshua Bel l erwas del i ver ed by Caesar ean s ecti on, but he had suffer ed hy p oxia res u lt in g i n sev ere brain d am age. Th e plaintiff s al l ege thatW ish ar d vi ol ate d the EM TA LA bytr ansfer rin g Jos h u a t o B ee c h G ro ve ins te ad of st ab i l izin g h im b y d eliv er in g h im , an d th at th e fa ilu re res u lte d in h is perm anent inj uri es. The EM TA LA was enact ed to a d d re ss the pr obl em o f pati en t “dum ping, ” in w hi ch hospi tal s would not provi de the sam e t re atm ent t o un in su re d pati ents as toN o. 11

- 3691 3 payi ng pati ents, ei therbyr efusi ng ca re to the uni nsured p at ien ts or b y t ra n sfe rrin g th em t o ot h er fac ilitie s. Johns on v. Uni v. o

f Ch i c ag o Hos pi tals , 9 82 F. 2d 230, 23 3 n. 7 ( 7th C ir. 19 93 ); Gate wood v. Was hi ngt on He al t hc areCorp. , 93 3 F
. 2 d 1 0 3 7, 1 0 3 9 ( D. C
. C i r . 1 9 9 1 )
. E MTA L A i mpo s e s t wo dut i es o n h o spi ta l s with res pec t to pa ti en ts who com e t o thei r em er gencyr oo m s: fir st, to pro vi de m edi cal scr eeni ng f orany em er gencyco n dit i on; and sec ond, as to any e m er gencyco nd i ti on, to st abi l i ze the pati ent pr i or t o a nyt r a ns fe r t o a no the r f a c i l i t y . 4 2 U. S
. C. § 1 3 9 5 dd. The i ssue i n thi s c ase i s whether the pl ai nti ff s had “co m e t o the e m er gencyr oo m ” of W ishard M em or i al H osp ital w he n th ey w ere tran sp ort e d i n th e W ishard am bul ance. The r egul ati ons to the EM TA LA , pro m ulg ate d by the Depart m ent o fH eal th and H um an S er vi ces’ C en ter for M ed icare a nd M ed icaid Services (“D H H S), provi de a de fi ni t i o n o fwh e n a p e r s o n i s de e med to h av e “ c om e t o th e e m er g e n c y roo m ,” b u t t h e 2 00 1 d efin iti on in effe c t a t the ti m e o fthe i nci dent w as subse que nt l y a m en ded. Bo thpa r ti es a gree th atunde r the 2003 defi ni ti on, the pla i nti ff s would nothave “co m e t o th e emerge nc y r o o m ” o fW i sh ar d, a nd the r efo r e th e cl ai m cou ld n ot proce ed. The co re i ssue, then, i s which defini ti on a pp l i es. T h e 2 00 1 re gu lat ion p ro vid es th at : C om es to th e e m er ge n c y d ep ar tm en t m ea n s . . . th at th e ind ivi d ua l is on the hos p ital p rop erty. For pu rp o s e s o fth i s s e c t i o n . . . [ p ] r o p e r t y . . . i n c l u d e s a mbul ances own ed and opera ted bythe hospi talev en i fthe am bul ance i s no t o n hospi talgr ounds.4 N o. 11

- 3691 42 C.F
. R. § 489. 24(b) ( 2001 )
. That r egul ati on was l ate r a men de d i n 2 0 0 3 , a nd a l tho ugh i t s t i l l pr o v i de d t hat a n i nd i vi du ali n an am bul ance o w ned and operat ed by the h o s pi t a li s de e med t o h a v e c o me t o the e merge ncy ro om , i t a l so sta ted thatsuch per son i s no t co nsi dered to h av e c om e t o th e e m er ge n c y ro om of th at h os p ita l if ( i ) ( t ) he a mbu l a nc e i s o pe r a t e d u nd e r c o mm un i t y wi de em er gencym edi calse rv i ce ( EM S) pro toc ol s that dir ect i t t o tr anspor t the i nd i vi du alto a hospi talo ther th an the ho spi ta ltha t o wns the a m bul an ce . . . [ or] ( i i ) [ t] he am bul ance i s op erate d at the di re cti on o f a p h ys icia n w h o is n otem p loy ed or ot h er w ise affiliate d w i th the hos pit althato w ns the am bul ance. 42 C.F
. R. § 489. 24 (b ) (200 3)
. The W i shar d am bul ance w as oper atin g u n d erEM S prot oco l s a t the ti m e i t t ra nsp orted the p lai nt iffs t o Be ech Grov e, an d therefore und er the 2003 am endm ent the pl ai nti ff s would notbe deem ed to have co m e t o th e W i shar d em er gencyr oo m by thei r prese nce in that am bul ance. Bec au se the 2 00 3 amendmento cc ur r ed afte r the i nc i de nt, the que s t i o n i s wh e the r i tc a n b e a pp l i e d r e t r oa c t i v e l y i n d e t e r mi n i n gw h e th e r th e p l a i n t i ff s h a d c o me t o th e e me r g e n c y r o o m a tWi s h a r d u n d e r th e E MTA L A. InBowen v. Ge orge t own U ni ve rs i ty Hospi t al , 48 8 U.S
. 20 4, 20 8- 09 ( 19 88 ) , the S upr eme Co ur t he l d tha t ana dm i ni str ati ve a gency m ay not prom ulg ate r etr oac ti ve rul es unle ss Congre ss has provi ded the age ncy w i th ex p re ss au th o r i tyt o do s o a nd, e ve n i fs ucha utho r i tyi s g i ve n, an ag ency ru le w i l lnotbe acco rded re tr oac ti ve effect u nl ess the age ncy use s l anguage i n the rul e e xp re ss lyN o. 11

- 3691 5

re quir i ng tha t r esul t. W e hav e r eco gni zed, however, that not al lrule s cr eat e s ubstanti ve changes

. S om e ru l es si m pl y c l ar i fy u ns et tl ed o r c o nfus i nga r ea s o fl aw a nd ra therthan changi ng the l aw , t hose r ule s m er el y r est ate w hat the la w h as al w ays bee n acco rdi ng to the age ncy. Clayv. Jo hnso n , 26 4 F
. 3d 744, 74 9 ( 7th Ci r. 20 01)
. S uch a cl ar i fyi ng r ule “ c an be appli ed to the case athand j ust as a j ud i ci aldeter m i nati on co nstr uinga sta tute can be appli ed to the case athand, ” a nd does notr ais e issues o f r e tr oa c tiv ity
. Id. ; M i ddl e t on v. Ci ty of Chi cago , 57 8 F
. 3d 655, 63 3 ( 7th Ci r. 20 09)
. There f or e, the dispos i ti ve q u es tio n is w h e t h er th e 2 00 3 a m en d m en t o f th e d efin iti on o f “ c om es to the e m er gencydepartm ent” w as m er el y a cl ar i fi cati on o fthe m eani n g of th at phrase, o r whethe r i t pr es en te d a s ubs tan ti ve c ha ng e i n the de fi ni ti o n. The dis tr i ct c ou rt hel d that the am ended d efi ni ti on o f “co m es to the em er gencydepartm ent” w as a cl ar i fi cati on that appli ed re tr oac ti vel y, and gr anted sum m ar y j ud gm en t in favor of the d efend an t. I n so h olding, the cou rt g av e defer en ce t o the DHH S ’ c hara ct er i za ti o n o fthe 2003 am en d m ent a s a cl ar i fi cati on, and concl ud ed that the am en d m ent was i ntended to al l evi ate co nfusi on su r r o undi ng ho spi ta l

- o wned a mb ul an ce s o per at i ng u n d er th e E M S p ro to c ols . On ap p ea l, th e p lain tiffs ch all enge both of th ose bas es. They a rgue thati t i s no t cl ear th atthe DHH S i n f ac t co ns i der ed th e 20 03 amendment to be a c lar ifica tio n . M or eo ve r , t h e y as se rtth at ev en if th e DH H S di d c ha r ac te r i ze i t as a c l ar i fi ca ti o n, the dist ri ct c ourtga ve u n d ue defer ence to that deter m i nati on a nd er re d i n f ai ling t o conduct i ts own anal ysi s t o asce rt ai n w hetherthe am endm ent was a substa nti ve ch an g e o r a c l ar i fi ca ti o n.6 N o. 11

- 3691 Ind et er m in in g w h et h er a r u le c on st itu te s a ch an ge in la w ora c l ar i fi ca ti o n o fe xi st i ngl aw, the i nt en t o fthe prom ulg ating ag ency m ust be acc or ded grea t wei ght. Clay, 26 4 F
. 3d at 749. W e there f or e wil ldeferto an age ncy’ s e x p re ssed int ent that a r egul ati on be deem ed a cl ari fi cati on unl ess the pri ori nter preta ti on o fthe re gu lat ion is “p at en tly inc on sis te n t” w ith th e la te r on e. Id. W e a gr ee w i th the di str i ct c ourt ’ s concl usi on that the DH SSco nsi dered the 20 03 re gul ation to be a cl ar i fi cati on of th e defi ni ti on o f“co m es to the e m er gencydepartmen t
. ” In i t s F i na lR ul e i mpl e men t i ngthe 2003 a men dm ent, the DH H S re peatedl y s tat ed that the changes w er e cl ar i fi cati ons i n or der t o add re ss confusi on a s t o the s cope o fthe 2001 defin ition. In f act, the ti tl e s tat es “Cla ri fyi ng Pol i ci es Rel ate d to the Res ponsibi l i ti es of M ed ica re -P ar tic ip at in g H os p ita ls in T re at in g In d ivid u als W i thEm er gen cyM edi ca lCo ndi ti o ns . ” 68 F R 5 32 22
. The F i na lRul e e xpli ci tly s ta te s th ati t “b o thr ei te r at ed th e age nc y’ s inter preta ti ons und erEM TA LA and propos ed cl ar i fyi ng change s r el ating to th e im ple m entat i on o f the EM TA LA pro vi si ons. ” Su m m a ry, 68 FR 53 22 2. It i nd i cate d that the “r ei ter ati ons and cl ar i fyi ng change s ar e nee ded to ensur e uni f or m and consi ste nt appli cati on ofpolicy and to avo i d any m i sund er sta nd i ng o f EM TA LA r equi re m ents by i nd i vi du als, physi ci ans, o r hospi talem plo yee s. ” Id. M o r eo ve r, i n a ddr es singthe defini ti on o f“com es to the e m er gencydepartm ent” speci fi cal l y, DH H S sta ted “we propos ed to cl ar i fy, at pr o po se d r ev i se d § 4 89
. 24 ( b) , i n pa ragrap h ( 3) o fthe definitio n of‘ Com es to the e m er gencydepartm ent, ’ an e xc e pt i o n t o o ure xi s t i ngr ul e r e qu i r i ngEMTALA a p-N o. 11

- 3691 7 pl i cabi l i tyt o ho spi ta l s tha t o wn an d o per at e ambul ances. W e pr oposed to acco unt f orhos pit al

- own ed am bul ances oper ating und er com m unitywide EM S prot ocol s. ” XII
. EM TA LA Appl i ca b i l i ty to Hos pi t al

- O wne d Am b ul anc e s (§ 4 89. 24( b ) ) B. Pr ovi s i ons of thePr opos e d Rule, 68 FR 53 256. T h e D H H S then pro ceeded ag ai n to r eferto i ts rul e a s a “pro posalto cl ar i fy th at EM TA LA does not a p p l y t o a h o s p i t a l

- o wn e d a mb u l a n c e w he n th e a mb u lan c e is op er at in g u n d er co m m u n ity w id e p ro to c ols that re quir e i t t o tr ansp or t a n i nd i vi du alto a hospi tal othe r than the hos pit alth at o w ns the am bul ance. ” X II
. E M T A LA A pp lica bility to H o spita l-O w ned A m b u la nc es (§ 489.24(b )), C. Sum m ary o f P ubli c Com m ents and D epart

m enta l R espo nses, 68 FR 5 3256
. Those s ta tem ents ar e unam bi guous, and w e a gr ee w i th the dist ri ct cour t that the DH H S consi dered th e 2 003 am en d m ent t o be a cl ar i fi cati on r atherthan a s ubstanti ve change. W e d efer t o that deter m i nati on unl ess the 2001 de fi ni t i o n i s pa t e nt l y i nc o ns i s t e ntwi th the 2 0 0 3 a men dm en t. Clay, 26 4 F
. 3d at 749. T h e p lain tiffs n ev er th e l es s c laim th at th e D H H S is m is t a k en i n th at ch aract erization, an d that the tw o de fi ni ti o ns are i nc o ns i st en t. Acco r di ngt o the pl aint i ff s, the 2003 a m en dm ent was a re sponse to a s i tuati on not prese nt i n 200 1

— the use of the Em er gen c y M edi cal Se rv ice in d et er m i n i n g h ow am b u lan c es w ou ld be d ire cted. W i th the advent ofthe EM S pr ot ocol s, i n w hi ch am bul ances w er e o p er ate d und erthe dir ecti on o ftho se prot oco l s a nd notunder the di re cti on of the hospi tal own i ng the am bul ance, questi ons had ari sen a s t o8 N o. 11

- 3691

w hetherthe i nd i vi du alin such a n am bul ance woul d be co ns i der ed to ha ve c o m e to the e m er g en cyr o o m o fthe ho spi ta ltha t o w ned the a m bul an ce . The a m en dm en t was de si g ne d t o a ddr es s th atc o nfusi o n a nd s etf o r tha r ul e f o r s ucha c i r cumst an ce . The pl aint i ff s p oint to the advent o fthe EM S prot oco l s a s e vi dence thatthe change i s a subst anti ve one, ar gui ng that a subst anti ve change w as n ec es sa ry to ad ap t t o th at n ew circ u m st an c e. Sp ec ific ally , th e p lain tiffs rep ea te d l y a ss er t t h at th e 2 00 1 d efin iti on was “pl ai n and si m ple and had n o ex cepti ons: i fan i nd i vi du alwas i n a h os pit al

- own ed am bul ance, s/he had ‘c om e t o th e e m er ge n c y d ep ar tm en t’ o f th at h os p ita l.” A ccor ding to th e p lai nti ff s, the 2003 defi ni ti on cr eat ed tw o excepti ons f ort h e 2001 defi ni ti on, thus fund am en ta l l y c ha ng i ng, r athe r tha n c l ar i fy i ng, the me an in g of “ c om es to th e e m er ge n c y d ep ar tm en t.” Tha t ch ar ac te r i za ti o n o f th e 20 01 defi ni ti o n bythe pla i nti ff s i gnor es i ts pla i n l anguage . The 20 01 defini ti on state d t h at a per son “co m es to the e m er gencydepartm ent” i fthe perso n i s o n hospi talp ro perty, and hospi tal proper ty i ncl ud es “am bul ances own ed and opera ted by the ho spi talev en i fthe am b u l ance i s no t o n hospi tal gr ounds. ” Th e p lai nti ff s’ st ate m ent that a per son ther ef or e had co m e t o the e m er ge n c y d epart m ent i fshe w as i n a “ ho spi ta l

- o wned a m bulance ” i g no r es the s ec o nd quali fi er, wh i ch i s th at the a m bul ance m ust be o w ned “and oper ate d by” a ho spi tal

. The 20 03 defini ti on cl ar i fi ed w hat i t m eant f oran a m bul ance to be “oper ate d b y” a ho spi tal

. The 20 03 am endm ent s peci fi cal l y c l ar i fi ed the sta tus of tw o si tuati ons i n w hi ch the a m bul ance w as own ed by the hospi tal but not as a practic al m at terN o. 11

- 3691 9

o p e r a t e d b y th e h o s p i t a l d u r i n g th a t t i me

— fi rs t in w hi ch the a mbu l an c e wa s o pe r a t e d u nd e r c o mm un i t y wi de EM S prot oco l s th at d i re ct i t t o tr anspor t the i nd i vi du al t o a h o s p i t a lo th e r th a n th e h o s pi t a l th a to wn s th e a mbul an ce , a nd s ec o nd i n whi chi t was o per at ed atthe dir ecti on o fa physi ci an wh o i s no t e m plo yed o r othe rwis e affiliat ed w i th the hos pit althato w ns the am bul ance. Tha t i s a cl as si c si tu at i o n o fa c l ar i fy i ngr egul at i o n. The pl aint i ff s’ e xc l us i ve f o cus o n the o wner sh i p o fthe a m bul ance, and thei r f ai l ure to re cogniz e the 20 01 re quir em en t th atthe am bul an ce musta l so b e o per at ed bythe ho spi ta l, mis se s th e cr i ti ca lpo i nt
. The ad ven t o fthe EM S prot oco l s ca used confusi on in that an am bul ance c ou l d be o w ned by a hos pit albut not oper ate d und eri ts dir ecti on. The 20 03 re gul ati on cl ar i fi ed w i th r espectto th at an d an ot h er r e c u rrin g s itu at ion, th at th e in d ivid u als w oul d not be deem ed to have co m e t o the em er gency ro om o fthe hospi talbec ause the a m bul ance was under the o perat i on o fo ther s. There i s no thi ng i nconsi ste nt in t h e 2003 and 2001 defini ti on s. The two ar e co nsi ste nt i n hol ding that an i nd i vi du alwil lbe deem ed to have com e to the e m er gency departm ent i fthat p er son i s in an am bul ance o w ned and opera ted by the hospi tal

. The 20 03 defini ti on m er el y prov id ed guidance a s t o w hat i t m eans f oran am bu l ance t o be “ oper ate d by” a ho spi tal

. The di str i ct c ourtpro perl y hel d t h at the 2 003 am endm ent i s a cl ar i fi ca ti o n, whi chthe r efo r e appl i es i n int er p retingthe m ean ing of th e 2001 la n g u age. Bec au se th e W ishard am bu lan c e was o perat i ng under the EM S prot oco lat the t i m e the pl ai nti ff s were in it , the pl ai nti ff s had not10 N o. 11

- 3691

co m e to the W i sh ar d e m er g en cy d ep ar tmentunde r the EM TALA , a nd the pl aint i ff s’ c l ai m c anno t su cc eed. The deci si on o fthe d i str i ct c ourtgr anti ng sum m ar y j ud gm ent in f avo r ofthe defe nd ant i s A FFI RMED .

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