Supreme Court of Texas

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No. 20-0681

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Columbia Valley Healthcare System, L.P. d/b/a Valley Regional 

Medical Center,

Petitioner,

v.

A.M.A., A Minor, by and through his mother, Ana Ramirez, as 

next friend and Ana Ramirez, Individually, 

Respondents

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On Petition for Review from the

Court of Appeals for the Thirteenth District of Texas

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Argued February 23, 2022

JUSTICE YOUNG delivered the opinion of the Court.

Before respondent A.M.A. was born, nurses had observed his 

heartrate dropping to dangerous and even nondetectable levels for 

extended periods before they summoned the obstetrician. A.M.A. was 

deprived of oxygen for these periods because, as became apparent upon 

his delivery, the umbilical cord had become tightly wrapped around his 

neck. A.M.A. survived but was soon diagnosed with cerebral palsy. 

Following trial, a jury awarded a substantial amount for A.M.A.’s future 
2

healthcare expenses. At petitioner’s request, the district court applied 

the periodic-payments statute in the Texas Civil Practice and Remedies 

Code to the award of future medical expenses. We recently addressed 

that statute in Regent Care of San Antonio, L.P. v. Detrick, 610 S.W.3d 

830 (Tex. 2020). But because we decided that case after the district court 

rendered judgment, neither the court nor the parties had the benefit of 

its guidance. We conclude that the district court erred in how it 

structured the periodic payments and remand to that court for further 

proceedings that will allow it, in light of Regent Care and today’s 

decision, to render a judgment that complies with the periodic-payments 

statute. 

I

Ana Ramirez, A.M.A.’s mother, went to Valley Regional Medical 

Center for premature labor—she was 33-weeks pregnant—after her 

water broke on a Friday evening.

1 Her obstetrician, Dr. Martinez, 

instructed the nurses to monitor the baby’s heartbeat, then went home 

for the night, leaving the mother and her unborn baby in the nurses’ 

hands over the weekend. A.M.A.’s heartbeat in utero dropped for about 

two minutes shortly after midnight on Sunday. Twenty minutes later, 

his heartbeat dropped for seven minutes. Finally, after another twenty 

minutes, the baby’s heartbeat dropped to the point where the nurses 

could not detect it. Even then, the nurses did not call Dr. Martinez—

they waited for another twenty minutes. 

1 The petitioner is Columbia Valley Healthcare System, L.P. d/b/a 

Valley Regional Medical Center. We refer to it as “Valley Regional.” 
3

After the nurses called the doctor, it took him about nineteen 

minutes to arrive at Valley Regional. His ability to act was impeded 

because no ultrasound had been done, even though he had ordered a 

“stat” ultrasound when the nurses called him. The ultrasound 

technician arrived only after Dr. Martinez did. Once the ultrasound was 

started, the doctor saw that there was minimal heart activity, ordered 

an emergency c-section, and proceeded immediately to the operating 

room. After further logistical delays, including obtaining Ramirez’s 

signature on additional forms, A.M.A. was finally delivered. The 

umbilical cord had become tightly wrapped around his neck. Because of 

the lack of oxygen to his brain, A.M.A. was later diagnosed with cerebral 

palsy.

Ramirez sued Valley Regional on behalf of A.M.A., alleging that 

the nurses’ delay caused A.M.A.’s cerebral palsy. At the close of 

evidence, Valley Regional’s proposed jury charge asked the court to 

question the jury about A.M.A.’s life expectancy and about the annual 

amount of any future healthcare expenses. The trial court denied Valley 

Regional’s proposed charge and Valley Regional objected to the denial. 

The jury found for A.M.A. and awarded $10,330,000, divided as follows: 

$62,000 for past healthcare expenses, $9.06 million for future healthcare 

expenses until A.M.A. turns 18, and $1.208 million for future healthcare 

expenses after he turns 18. 

Before trial, Valley Regional had moved the trial court to 

structure any jury award of future medical expenses as periodic 

payments under the periodic-payments statute, which is codified as 

Texas Civil Practice and Remedies Code Chapter 74, Subchapter K. 
4

When properly invoked, the periodic-payments statute requires the trial 

judge to order that the award for future healthcare expenses be paid “in 

whole or in part in periodic payments rather than by a lump sum 

payment.” Tex. Civ. Prac. & Rem. Code § 74.503(a). 

About a month after the jury trial concluded, the trial judge held 

a hearing to determine how to form the court’s judgment, including how 

to structure periodic payments and how to ensure that any required 

periodic payments would be made. Valley Regional’s principal position 

was that, under the statute and the Constitution, separate questions 

about life expectancy or annual medical expenses should have been 

submitted to the jury. Despite the lack of separate questions, however, 

evidence presented at the trial had addressed these topics. A.M.A.’s 

expert, Dr. Willingham, testified that A.M.A.’s life expectancy was 

thirty-two years. Valley Regional’s experts testified that A.M.A.’s life 

expectancy was likely up to seven or eight years-old, but that he was 

“highly unlikely” to live past age ten. Each party presented annual 

healthcare costs that tracked their different life-expectancy evidence. 

Valley Regional presented evidence of annual healthcare costs of 

$604,000 per year and for its expert’s opinion that A.M.A. had five years 

of life remaining. A.M.A.’s expert submitted life-care plans that 

included annual medical costs to age eighteen, and from that age to “end 

of life” at age thirty-two. 

A.M.A. noted some of this evidence at the hearing and in 

subsequent briefing about the structure of the periodic payments. The 

district court found A.M.A.’s first proposed judgment insufficiently clear 

and directed A.M.A. to revise it. The district court repeatedly offered 
5

Valley Regional the chance to provide its own proposed judgment, 

including how it would structure the periodic payments, but Valley 

Regional agreed only to offer objections to A.M.A.’s proposed judgment, 

which it did. About three weeks later, the trial court held a hearing on

A.M.A.’s second proposed judgment, which included modifications and 

clarifications to the proposed structure for periodic payments. 

A.M.A. then submitted its third proposed judgment and Valley 

Regional submitted its objections. The trial court signed A.M.A.’s 

proposal as its final judgment, which ordered the award structured as 

follows: (1) five periodic payments of $604,000 from a funded bank 

account, to begin on A.M.A.’s “fourth birthday, which will be on October 

27, 2018, and the payments shall continue on his birthday each year 

through his 8th birthday on October 27, 2022,” and (2) a lump-sum 

payment of the remaining $7,310,000 to a special-needs trust, which 

allows funds to be used to maintain good health, safety, and well-being, 

in addition to medical expenses. In the event of A.M.A.’s death, the 

special-needs trust mandates that any remaining principal and income 

in the trust revert to his heirs, which would be his father and mother. 

The district court also awarded prejudgment and postjudgment interest. 

After the trial court signed the judgment, Valley Regional 

requested findings of fact and conclusions of law concerning the periodic

payments. The district court denied that request. Valley Regional also 

challenged the judgment through a series of other motions, each of 

which the trial court denied. 

Valley Regional perfected a timely notice of appeal and brought 

its case to the Thirteenth Court of Appeals. In multiple issues, it raised 
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three main challenges to the district court’s judgment. First, it 

challenged the legal and factual sufficiency of the evidence for medical 

liability, again predicated on causation. Second, it claimed that it had 

been denied its right to a jury trial, on the ground that life expectancy 

and annual medical expenses should have been submitted to the jury, 

as Valley Regional repeatedly asked. Finally, it contended that the 

periodic-payment statute is ambiguous and that the trial court had 

improperly applied that statute in several respects. 

The court of appeals overruled each of Valley Regional’s issues 

and affirmed the judgment of the district court.2 We granted Valley 

Regional’s subsequent petition for review.

II

We granted this case to further address the complications that 

inhere in a trial court’s duty under the periodic-payments statute. We 

addressed the statute most recently in Regent Care. Notably, the trial 

in this case predated that decision, and we believe that proceedings in 

the district court would have been different had our opinion been 

available, which informs our decision to remand the case to that court. 

Regent Care does not resolve every issue presented here, however, so we 

begin by laying out the statute and how we addressed it in Regent Care, 

and then turn to the issues presented here. 

A

The heart of the periodic-payments statute is Texas Civil 

Remedies & Procedures Code § 74.503, which provides that “[a]t the 

2 640 S.W.3d 867 (Tex. App.—Corpus Christi–Edinburg 2020).
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request of a defendant physician or health care provider or claimant, the 

court shall order that medical, health care, or custodial services 

awarded in a health care liability claim be paid in whole or in part in 

periodic payments rather than by a lump-sum payment.” Id. § 74.503(a)

(emphasis added). “At the request of a defendant physician or 

healthcare provider or claimant,” moreover, “the court may order that 

future damages other than medical, health care, or custodial services . . .

be paid in whole or in part in periodic payments rather than by a lump 

sum payment.” Id. § 74.503(b) (emphasis added). The statute further 

provides that:

(c) The court shall make a specific finding of the dollar 

amount of periodic payments that will compensate the 

claimant for the future damages.

(d) The court shall specify in its judgment ordering the 

payment of future damages by periodic payments the:

(1) recipient of the payments;

(2) dollar amount of the payments;

(3) interval between payments; and

(4) number of payments or the period of time over 

which payments must be made.

Id. § 74.503(c)–(d).

The periodic payments are to be made “to the recipient of future 

damages at defined intervals.” Id. § 74.501(3). Such “[p]eriodic

payments, other than future loss of earnings, terminate on the death of 

the recipient.” Id. § 74.506(b). Finally, “[f]or purposes of computing the 

award of attorney’s fees,” the court must reduce the periodic payments 
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to present value “based on the claimant’s projected life expectancy,” id.

§ 74.507. 

We first interpreted and applied the periodic-payments statute in 

Regent Care. We held that the “court may order that an award of future 

medical expenses be paid periodically either in whole or in part,” but 

emphasized that the total amount awarded must be the amount that the 

evidence shows will compensate the claimant for future damages. 610 

S.W.3d at 837. Further, when the trial court orders periodic payments, 

it “shall specify the amount, number, timing, and recipient of those 

[periodic] payments in its judgment.” Id. 

To support such a judgment, the party requesting the periodicpayments order must identify “for the trial court evidence regarding 

each of the findings required by section 74.503 . . . .” Id. Because these 

findings are not indispensable to the claim itself—that is, the underlying 

medical liability claim—the trial court may need to receive additional 

evidence if the record does not already contain sufficient evidence to 

justify a decision under the statute. Id. Any such evidence that the trial 

court receives, of course, may not contradict what the jury found. Id. at 

837–38. After all, the statute “gives the trial court no discretion to craft 

its own award of damages inconsistent with the jury’s verdict.” Id. at 

838. In structuring the award, the trial court must also identify 

evidence to support the amount it divided between any lump-sum and 

periodic payments. Id. at 837. 
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B

We now turn to the issues that Valley Regional brings to this 

Court.3 Valley Regional repeatedly asked the district court to submit 

life expectancy and annual medical expenses as specific questions to the 

jury. The district court repeatedly declined to do so. Valley Regional 

properly preserved its objections to each denial, and now contends that 

these denials violated both the Texas Constitution and the periodicpayments statute. 

We reject Valley Regional’s constitutional challenge. Like any 

litigant, Valley Regional certainly had a right under the Texas 

Constitution to a jury determination of every fact essential to the 

resolution of the claims brought against it. See, e.g., Oncor Elec. Delivery 

Co. LLC v. Chaparral Energy, LLC, 546 S.W.3d 133, 144 (Tex. 2018). 

But A.M.A.’s claim remains one for medical malpractice, and Valley 

Regional received a jury trial on that underlying claim: whether its 

negligence proximately caused A.M.A.’s injuries. 

Additionally, as we detailed above, the jury heard evidence on the 

requested questions from experts. Both parties’ experts testified 

3 Before presenting its periodic-payments challenges, Valley Regional’s 

briefing also challenged the legal sufficiency of the evidence to sustain the 

jury’s liability findings. A.M.A.’s burden was to put on evidence sufficient to 

show that Valley Regional’s negligence proximately caused A.M.A.’s injuries. 

We have reviewed the record and find no reversible error in the lower courts’ 

refusal to sustain Valley Regional’s challenge to verdict. See, e.g., Gunn v. 

McCoy, 554 S.W.3d 645, 658 (Tex. 2018) (evidence in a medical-malpractice 

case is legally sufficient when it “rises to a level that would enable reasonable 

and fair-minded people to differ in their conclusions”) (citation omitted). 

“[F]urther discussion of the[se] issues would not add to the jurisprudence of 

the State. In reaching this conclusion, we express no opinion on the court of 

appeals’ reasoning.” Regent Care, 610 S.W.3d at 839.
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concerning life expectancy and annual healthcare expenses. That 

evidence necessarily formed part of the jury’s assessment of damages. 

The judge, in turn, was required to base her orders concerning the award 

structure on the evidence presented at trial.4 The Constitution does not 

require a jury to go further and allocate how or when its award will be 

paid, which are the points that form the basis of Valley Regional’s 

objection. Finally, the periodic-payments statute does not implement a 

constitutional guarantee. It instead represents a legislative choice to 

provide healthcare providers an option, subject to the statute’s 

provisions, to pay damages awards periodically rather than in a lump 

sum. Absent the statute, the entire damages award would be due upon 

judgment. 

A jury may still be required, of course, if a statute so requires, 

even if the Constitution does not. But as we indicated in Regent Care, it 

is not incumbent upon the court to submit granular questions relating 

to the proper structuring of periodic payments to the jury. See 610 

S.W.3d at 837 (recognizing the court’s discretion to make decisions 

regarding the award’s structure). The statute does not require the jury 

to make findings of life expectancy or an annualized assessment of 

medical expenses. See Tex. Civ. Prac. & Rem. Code § 74.503. Rather, 

as we repeatedly noted, the statute expressly directs “the court,” under 

specified conditions, to structure the award as periodic payments (or, if 

4 As we explain below, the trial court’s judgment constituted an abuse 

of discretion—but the error was not traceable to an improper failure to submit 

questions to the jury. 
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appropriate, partly as periodic payments and partly as a lump sum paid 

immediately). Id.; Regent Care, 610 S.W.3d at 837.5 

Subsections 74.503(c) and (d) require the court to make specific 

findings on the dollar amounts for “future damages.” Regent Care

interpreted these provisions as obligating the party that requests the 

periodic payments to “identify for the trial court evidence regarding each 

of the findings required by section 74.503.” 610 S.W.3d at 837 (emphasis 

added). The trial court’s duty to structure the jury award into periodic 

payments or a lump sum based on life expectancy and annual medical 

expenses means that the statute, like the Constitution, does not require 

the jury to make those specific determinations. At the same time, a trial 

court retains the discretion, based on the circumstances of the case, to 

present questions to a jury that may assist the court in its discharge of 

its duty under the statute. As we discuss below, the court must have 

evidence to structure any periodic-payments award; presenting 

questions to the jury may eliminate doubts in some cases or protect a 

resulting judgment from reversal in others. We hold only that a court’s 

refusal to submit such questions, here or in other cases, is not in and of 

itself error.6

5 Neither does Texas Rule of Civil Procedure 278 require that these 

questions be submitted to the jury. We have interpreted this rule to require 

submitting “controlling questions” to the jury. Triplex Commc’ns v. Riley, 900 

S.W.2d 716, 718 (Tex. 1999). For the same reasons that the statute does not 

require the jury to make these findings, neither does the rule. 

6 We express no opinion about whether circumstances could ever make 

it reversible error for a trial court to refuse a party’s request that it instruct 

the jury to answer specific questions on these or related topics. 
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C

Although there is no general need for (or entitlement to) the 

court’s submission of granular questions to the jury in the way that 

Valley Regional contends, that does not mean that a trial court is 

unconstrained in structuring a periodic-payment award. To the 

contrary, the entire structure of the statute makes it essential that the 

trial court rely on and point to probative evidence regarding its 

disposition. See Regent Care, 610 S.W.3d at 837. In this case, such 

evidence must support the court’s decision to have only five years of 

periodic payments, to place the rest of the amount (some 70% of the 

total) in a lump sum, and to place that lump sum in a special-needs trust 

that is structured as this one was. See id. (“In other words, any division 

between lump-sum payments and periodic payments of damages that 

will be ‘incurred after the date of judgment’ must be founded in the 

record.”).7

Particularly given the absence of any specific jury findings here, 

we see nothing in the trial court’s or the court of appeals’ decisions—or 

A.M.A.’s briefs—that shows how the evidence justifies the way the trial 

court ordered the periodic payments to be structured. We identify three 

key and interrelated problems. 

First, the trial court’s periodic-payments order contradicts the 

jury’s verdict. The jury awarded an amount for the first eighteen years 

of life and then went beyond that to award a smaller (but still 

substantial) award for A.M.A.’s expenses after he turned eighteen. The 

7 Petitioner does not challenge the use of a special-needs trust as a 

general matter. We express no opinion on that question.
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court, however, limited periodic payments to only five years (up through 

A.M.A.’s eighth birthday). To calculate those five years of payments, the 

court relied on the testimony of Valley Regional’s expert, who presented 

evidence that A.M.A. would require $604,000 in annual medical 

expenses. The rest of the award—everything except for those five years

of periodic payments—would be paid immediately to an irrevocable 

special-needs trust. By only requiring Valley Regional to pay periodic 

payments up to A.M.A.’s eighth birthday, the trial court contradicted the 

jury findings, which awarded a far larger amount to last until his 

eighteenth birthday (then proceeded to assume at least some expenses 

beyond that time). The verdict contemplates the need to go beyond age 

eight. The statute affords considerable discretion to the trial court in 

structuring periodic-payments awards—but the court has no discretion 

to “contradict the jury’s findings on any issues submitted to it.” Regent 

Care, 610 S.W.3d at 837–38. 

Second, the lump-sum requirement, with the remainder of the 

award going to the special-needs trust, violates the statute’s 

requirement that “[p]eriodic payments, other than future loss of 

earnings, terminate on the death of the recipient.” Tex. Civ. Prac. & 

Rem. Code. § 74.506(b). For the five annual payments, the judgment 

correctly recites that, “[i]n the event that [A.M.A.] dies during the five 

year period in which the periodic payments are to be paid, [Valley 

Regional’s] payment obligation terminates and [Valley Regional] is 

entitled to withdraw the remaining funds in escrow.” But the rest of the 

award, despite being for future medical expenses, is structured to evade 

that requirement. Under the terms of the judgment, the balance of the 
14

special-needs trust will not be restored to Valley Regional if it is not used 

for A.M.A.’s medical expenses; instead, it goes to A.M.A.’s parents. 

Beyond being an abuse of discretion to structure periodic payments in a 

way that contravenes the jury’s verdict, it is an abuse of discretion to 

impose a lump-sum payment without evidence supporting the need for 

an immediate payment of a lump-sum payment.

Finally, even aside from the possible violation of § 74.506, the 

trial court erred by pointing to no evidence that could justify the division 

between periodic payments and a lump sum. It is true, and Regent Care 

acknowledged, that the statute authorizes a trial court to order only part

of the award to be paid in periodic payments. But only a particular kind 

of evidence unlocks that discretion, which is not unfettered. If, “for 

example, the record shows a lump-sum payment is warranted to meet 

expenses expected soon after trial,” 610 S.W.3d at 837, or if there is 

evidence that specific amounts can be expected to occur but in irregular 

patterns, then a court may—with caution—be justified in withdrawing 

a set amount from periodic payments. The district court relied on no 

such evidence of current expenses (including attorney’s fees due) or 

immediate medical needs here. As the award stands, the trial court 

pointed to no evidence in the record to justify why any amount should 

be extracted from the periodic-payment amounts and made payable as 

a lump sum. For this reason, too, therefore, the lump-sum award—

diverted into a trust that will revert to plaintiffs, and not Valley 

Regional, if not used for the specified purposes—ignores the statute’s 

text and structure. 
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D

The trial court’s order amounts to an abuse of discretion. But our 

only decision addressing the periodic-payments statute was released 

after the trial court made its decision. Neither the parties nor the court 

had the benefit of our analysis in Regent Care, which makes the district 

court’s order and the parties’ presentation of their arguments more 

understandable. 

We therefore remand the case to the district court, which should 

have another chance to structure the award—and a first chance to do so 

based on Regent Care and today’s decision. Both parties are entitled to 

explain, and support with existing evidence, why a particular structure 

is sensible. The parties should have the opportunity to address whether 

the presentation of additional evidence that does not contravene the 

jury’s verdict would be necessary or helpful to the trial court in 

discharging its task of rendering a lawful judgment that complies with 

the periodic-payments statute.8

III

The judgment below is reversed in part and the case is remanded 

to the district court for further proceedings that will allow it to render a 

8 Valley Regional also challenged the award of attorney’s fees. The 

periodic-payments statute authorizes the plaintiff to pay fees from the award, 

see Tex. Civ. Prac. & Rem. Code § 74.507, and the trial court did not err by 

authorizing the payment of such attorney’s fees. The statute requires the trial 

court to reduce the total amount of periodic payments to net present value to 

facilitate computing any attorney’s fees obligation. Because the periodicpayments structure itself must be revisited, net present value also must be 

recalculated on remand. We leave to the district court in the first instance any 

further assessment of whether or how its judgment affects the payment of fees.
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judgment that complies with the periodic-payments statute, including 

the statutory provision governing calculations necessary for the 

payment of attorney’s fees. In all other respects, the judgment below is 

affirmed.

Evan A. Young

Justice

OPINION DELIVERED: April 22, 2022