# S upreme C ourt of T exas

══════════ No. 20

- 0681

══════════ 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 ,

Respondent s

═══════════════════════════ ══ ══════════ On Petition for Review from the Court of Appeals for the Thir teenth District of Texas

═══════════════════════════ ══ ══════════
Argue d February 23, 2022

J USTICE Y OUNG 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 o xygen 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 future2

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 o f 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 i t 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, we nt 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 drop ped for about two minutes s hortly 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 th ough 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 delay s, including obtaining Ramirez’s signature on additional forms, A.M.A. was finally delivered

. T he 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 ju ry 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, V alley 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 i nvoked, 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 ). A bout a month after the jury trial concluded, t he 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 “h ighly 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 subsequ ent 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 offered5

Valley Regional the chance to provide its own proposed judgment, including how it would structure the periodic payment s , 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. T he trial court signed A.M.A.’s

propos al 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 remain ing $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 dea th, the special

- needs trust mandates that any remain ing 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 payment s

. The district court denied that request. Valley Regional also challenged the judgment through a series of other motions , each of which t he 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 raised6

three main challenges to the district court’s judgm ent. 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 th at statute in several respects. The court of app eals 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 belie ve 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 th e 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)

.7

request of a defendant physician o r 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) (empha sis added)

. “ A t 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 rath er 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 payments8

to present value “based on the clai mant’s projected life expectancy,” id. § 74.507. W e 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 83 7 . 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 per iodic

payments 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 t rial 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 f ound

. 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 837.9 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

. T he 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 C onstitution and the period ic

payment s statut e

. We rejec t 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] is sues 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 839.10

concerning life expectancy a nd 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 repres ents 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 s till 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 ju ry. 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 th e award as periodic payments (or, if

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

— but the error was not traceable to an improper failure to submit questions to the jury.11

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 amou nts for “future damages.” Regent Care interpreted these provisions as obligat ing the party that request s 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 (emphas is 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 determi nations. 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 evi dence 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 cas es, 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 “cont rolling 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 circumstance s 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.12 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 st ructuring 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 tha t is structured as this one was. See i d . (“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 an y specific jury findings here, we see nothing in the trial court’s or the court of appeals’ decision s

— 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 thre e 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 P etitioner does not challenge the use of a special

- needs trust as a general matter. W e express no opinion on that question

.13

court, however, limited periodic payments to only five years (up through A.M.A.’s eighth birthday). T o calculate those five years of payment s , 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

spec ial

- 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 a t 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 j ury’s findings on any issues submitted to it.” Regent Care , 610 S.W.3d at 83 7

– 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 tha n 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 the14

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 periodi c 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 e xtracted 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 th e statute’s text and structure.15 D The trial court’s order amounts to a n 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 pa rties 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 w ith 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 § 74.50 7, 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 comput ing an y attorney’s fees obligation . Becau se th e periodic

payments structure itself must be revisited, net present value also must be recalculated on remand

. W e leave to the district court in the first instance any further assessment of whether or how its judgment affects the payment of fees.16

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