United States Court of Appeals

For the First Circuit

No. 03-2256

JOAN RODRIGUEZ; DOMINGO DIAZ ROJAS; CONJUGAL PARTNERSHIP DIAZRODRIGUEZ,

Plaintiffs, Appellees,

v.

AMERICAN INTERNATIONAL INSURANCE COMPANY OF PUERTO RICO;

CORPORACION DE SERVICIOS INTEGRALES DE SALUD DEL AREA DE

BARRANQUITAS, COROZAL, NARANJITO Y OROCOVIS,

Defendants, Appellants.

APPEAL FROM THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF PUERTO RICO

[Hon. Jaime Pieras, Jr., Senior U.S. District Judge]

Before

 Torruella, Lynch, and Lipez, Circuit Judges.

Jeannette López de Victoria, with whom Pinto-Lugo, Oliveras &

Ortiz, PSC was on brief, for appellants.

Ramon L. Walker Merino, with whom Walker Merino Law Office was

on brief, for appellees.

March 23, 2005
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LYNCH, Circuit Judge. The question presented is whether

a regional diagnostic and treatment center which treats only

ambulatory patients and has an emergency room independent of a

hospital is subject to the requirements of the Emergency Medical

Treatment and Active Labor Act (EMTALA), 42 U.S.C. § 1395dd. 

The district court, ruling on a suit by the parents of a

four-month old baby girl who died after being seen in the emergency

room of a Diagnostic and Treatment Center ("Centro de Diagnóstico

y Tratamiento") ("CDT") in Corozal, Puerto Rico, held that an

EMTALA suit was actionable. We accepted the district court's

certification of this dispositive issue of law for interlocutory

appeal pursuant to 28 U.S.C. § 1292(b). We reverse, and order

dismissal of the suit. 

I.

The plaintiffs, a married couple, had a daughter, Lilliam

Diaz Rodriguez, who was born on October 10, 2000, with a

combination of congenital cardiovascular defects which made her

prone to cyanosis.

Lilliam vomited twice on March 3, 2001, and was taken by

her mother to the emergency ward at the Corozal CDT at 9:00 PM for

respiratory difficulties. The emergency ward doctor at the CDT

decided to transfer the child to the Pediatric Hospital at the

Puerto Rico Medical Center and inserted an endotracheal tube in

Lilliam. At 2:00 AM the next morning the child was transported to
1The plaintiffs also named Aeromed Services, Inc., which

provided the ambulance transportation from the Corozal CDT to the

Puerto Rico Medical Center, as a defendant. Aeromed is not

involved in this appeal.

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the Puerto Rico Medical Center with generalized cyanosis, and

Lilliam died sometime after arriving there.

The plaintiffs filed a federal suit for damages against

Corporacion de Servicios Integrales de Salud del Area de

Barranquitas, Corozal, Naranjito y Orocovis ("Corporacion"), the

owner of the Corozal CDT, and American International Insurance

Company of Puerto Rico ("AIICO"), Corporacion's insurer.1 The

plaintiffs asserted federal subject matter jurisdiction by alleging

that the defendants violated EMTALA by failing to provide the child

with an "appropriate medical screening examination" so as to detect

her emergency condition and by failing to stabilize the child's

condition properly before transferring her. See 42 U.S.C. §

1395dd(a)-(c). The complaint also alleged a Puerto Rico law claim

of medical malpractice by the defendants, and invoked the federal

court's supplemental jurisdiction.

The defendants moved for summary judgment. The

defendants, inter alia, denied the existence of federal subject

matter jurisdiction, contending that EMTALA does not apply to the

allegations in the complaint because the Corozal CDT is not a

"hospital" within the meaning of EMTALA.
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The district court denied the defendants' motion for

summary judgment on May 9, 2003. In its Opinion and Order, the

district court concluded that "the provisions of EMTALA apply to

CDTs in Puerto Rico that offer twenty-four hour emergency room

services, and that consequently, Plaintiffs have a colorable claim

under said statute."

The defendants then sought to certify the district

court's order for interlocutory appeal. After initially denying

the motion, the district court ultimately certified the

jurisdictional issue of whether the provisions of EMTALA are

applicable to CDTs for consideration before this court. Pursuant

to 28 U.S.C. § 1292(b), this court allowed the interlocutory appeal

after both appellants and appellees stipulated that the following

facts are not disputed:

1. The Corozal CDT is licensed under Puerto

Rico law to operate as a diagnostic and

treatment center.

2. The Corozal CDT provides 24-hour emergency

room services.

3. The Corozal CDT has executed a Medicare

Provider "Part B" agreement.

4. The Corozal CDT is not a hospital-based

facility nor is it attached to a hospital.

5. The Corozal CDT is not an inpatient

facility.

II.

We review de novo the grant or denial of summary

judgment, Univ. Emergency Med. Found. v. Rapier Invs., Ltd., 197

F.3d 18, 20 n.4 (1st Cir. 1999), as well as pure issues of law,
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Rational Software Corp. v. Sterling Corp., 393 F.3d 276, 276 (1st

Cir. 2005). 

In 1986 Congress enacted EMTALA in large part to solve

the problem of "dumping" of uninsured patients -- the problem of

hospital emergency rooms refusing to treat or transferring indigent

patients to public hospitals without first assessing and/or

stabilizing the patient's condition. See Correa v. Hosp. San

Francisco, 69 F.3d 1184, 1189 (1st Cir. 1995). EMTALA imposed some

limited substantive requirements on emergency rooms of hospitals

participating in the federal Medicare program. Specifically EMTALA

requires (1) that "a participating hospital afford an appropriate

medical screening to all persons who come to its emergency room

seeking medical assistance," and (2) "if an emergency medical

condition exists, the participating hospital must render the

services that are necessary to stabilize the patient's condition .

. . unless transferring the patient to another facility is

medically indicated and can be accomplished with relative safety."

Id. at 1190; 42 U.S.C. § 1395dd(a)-(c).

EMTALA created a private cause of action for damages for

violations of the Act against "participating hospitals." 42 U.S.C.

§ 1395dd(d)(2)(A). Congress conditioned those hospitals' continued

participation in the federal Medicare program on acceptance of the

duties imposed by EMTALA, "[n]eeding a carrot to make health-care

providers more receptive to the stick." Correa, 69 F.3d at 1189.
2The full definition of a CDT is "an independent facility or

one operated in conjunction with a hospital which provides

community services for the diagnosis and treatment of ambulatory

patients under the professional supervision of persons licensed to

practice medicine, surgery or dentistry in Puerto Rico." 24 P.R.

Laws Ann. § 331a(A)(4). There is no dispute over the fact that the

Corozal facility is not operated in conjunction with a hospital.

3In relevant part, EMTALA provides:

In the case of a hospital that has a hospital

emergency department, if any individual

(whether or not eligible for benefits under

this subchapter) comes to the emergency

department and a request is made on the

individual's behalf for examination or

treatment for a medical condition, the

hospital must provide for an appropriate

medical screening examination within the

capability of the hospital's emergency

department, including ancillary services

routinely available to the emergency

department, to determine whether or not an

emergency medical condition (within the

meaning of subsection (e)(1) of this section)

exists.

42 U.S.C. § 1395dd(a). The enforcement provision is limited to

"participating hospital[s]." Id. § 1395dd(d)(2)(A). A

"participating hospital" is in turn defined as "a hospital that has

entered into a [Medicare] provider agreement under section 1395cc

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The question of law posed by this case is whether a CDT,

defined by Puerto Rico law as "an independent facility . . . which

provides community services for the diagnosis and treatment of

ambulatory patients under the professional supervision of persons

licensed to practice medicine, surgery or dentistry in Puerto

Rico," 24 P.R. Laws Ann. § 331a(A)(4),2 qualifies as "a hospital

that has a hospital emergency department" under EMTALA, 42 U.S.C.

§ 1995dd(a).3 It is undisputed that the Corazal CDT is an
of this title." Id. § 1395dd(e)(2). The plaintiffs' reliance on

this definition to establish that the CDT is a hospital is

misplaced. The existence of a Medicare provider agreement is

relevant to whether a facility is "participating" for EMTALA

purposes, not to whether a facility is a hospital. Revisions to

section 1395cc, which defines the Medicare provider agreements, are

not relevant to the issues in this case. 

4The plaintiffs attempted at oral argument to bolster their

argument by pointing to amendments to an EMTALA regulation, 42

C.F.R. § 489.24. The regulation was amended after the filing of

this suit and the issuance of the district court's order. See 68

Fed. Reg. 53222, 53262 (Sept. 9, 2003). It now includes a

definition for "dedicated emergency department": 

Dedicated emergency department means any

department or facility of the hospital,

regardless of whether it is located on or off

the main hospital campus, that meets at least

one of the following requirements:

 (1) It is licensed by the State in which it

is located under applicable State law as an

emergency room or emergency department;

 (2) It is held out to the public (by name,

posted signs, advertising, or other means) as

a place that provides care for emergency

medical conditions on an urgent basis without

requiring a previously scheduled appointment;

or

 (3) During the calendar year immediately

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independent facility and is not attached to a hospital. CDTs are

"unique" to Puerto Rico and are "limited health facilities that

offer only outpatient services such as dentistry, X-ray, and

laboratory services." 

It is clear that EMTALA does not apply to all health care

facilities; it applies only to participating hospitals with

emergency departments.4 Further, the screening requirement under
preceding the calendar year in which a

determination under this section is being

made, based on a representative sample of

patient visits that occurred during that

calendar year, it provides at least one-third

of all of its outpatient visits for the

treatment of emergency medical conditions on

an urgent basis without requiring a previously

scheduled appointment.

42 C.F.R. § 489.24(b). The plaintiffs argue that this definition

means that the emergency room need not be a part of the hospital,

but can be "off campus." The amended regulation is irrelevant to

the issue, and in any case this argument misconstrues the

regulation. The "dedicated emergency department" may be physically

located off campus from the main hospital building, but it still

must be a part of a hospital. 

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EMTALA only applies to patients seeking treatment at the emergency

room, not elsewhere in a hospital. See Lopez-Soto v. Hawayek, 175

F.3d 170, 173 (1st Cir. 1999); Baber v. Hosp. Corp. of Am., 977

F.2d 872, 884 (4th Cir. 1992). It follows that if the Corozal CDT

is not a "hospital," EMTALA cannot apply to it.

As an amendment to the Social Security Act, EMTALA

incorporates the Act's definition of a "hospital." See Jackson v.

East Bay Hosp., 246 F.3d 1248, 1260 (9th Cir. 2001); cf. Correa, 69

F.3d at 1196 (looking to the Social Security Act's definition of

"state law" as the term is used in EMTALA). That definition of

"hospital" set forth in 42 U.S.C. § 1395x includes, in relevant

part:

(e) Hospital. The term "hospital" . . . means

an institution which -

(1) is primarily engaged in providing, by

or under the supervision of physicians,

to inpatients (A) diagnostic services
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and therapeutic services for medical

diagnosis, treatment, and care of

injured, disabled, or sick persons, or

(B) rehabilitation services for the

rehabilitation of injured, disabled, or

sick persons;

. . . 

(7) [and,] in the case of an institution in

any State in which State or applicable

local law provides for the licensing of

hospitals, (A) is licensed pursuant to

such law or (B) is approved, by the

agency of such State or locality

responsible for licensing hospitals, as

meeting the standards established for

such licensing . . . .

42 U.S.C. § 1395x(e). The Corozal CDT plainly does not meet these

requirements, for at least two reasons. First, it is not primarily

engaged in providing diagnostic and therapeutic or rehabilitation

services to inpatients, as required by subsection (e)(1). The CDT

is engaged entirely in outpatient, ambulatory care. 

Second, even if the requirement of subsection (e)(1) were

met, the other requirements of subsection (e)(7) must be met as

well. Puerto Rico law does not license or characterize CDTs as

hospitals. Indeed, Puerto Rico law clearly distinguishes between

hospitals and diagnostic and treatment centers. Compare 24 P.R.

Laws Ann. § 331a(A)(1) (defining a "hospital" as "an institution

which renders services to the community providing medical and/or

surgical diagnosis and/or treatment for illnesses or injuries

and/or obstetric treatment to hospitalized patients . . ."

(emphasis added)), with 24 P.R. Laws. Ann. § 331a(A)(4) (defining

a CDT as "an independent facility or one operated in conjunction
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with a hospital which provides community services for the diagnosis

and treatment of ambulatory patients under the professional

supervision of persons licensed to practice medicine, surgery or

dentistry in Puerto Rico" (emphasis added)). Even if a CDT

provides emergency services, that does not make it an emergency

room of a participating hospital.

The district court recognized that "under normal

circumstances, the Court would agree that a clinic, which is really

what a CDT is more akin to, does not fall under the auspices of

EMTALA." As a result, the district court found: 

[T]his case hinges not on the literal wording

of the statute, but rather on the end result -

- that the services provided by Defendant are

the types of services that this law is clearly

geared to cover. The statute is clear in the

nature of the services it pertains to: it

applies to emergency rooms, a facility that

has traditionally provided 24-hour services

identical to the one in the case at bar.

 

The district court found it would be "unconscionable" not to extend

EMTALA to cover CDTs with 24-hour emergency services because that

would have the effect of "excluding the poor population who

primarily rely on CDT services from the reaches of this all

important law." So, it concluded, the spirit of EMTALA, if not its

letter, was meant to cover the action against the defendants.

The district court erred. Federal courts are not free to

ignore the letter of the law in favor of the "spirit" of a law.

"[C]ourts interpret statutes primarily through detailed analysis of
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concrete statutory language, not by reference to abstract notions

of generalized legislative intent." Lopez-Soto, 175 F.3d at 176.

"[C]ourts must presume that a legislature says in a statute what it

means and means what it says there." Connecticut Nat'l Bank v.

Germain, 503 U.S. 249, 253-54 (1992). There is no legal ambiguity

about the language Congress used in EMTALA -- EMTALA requires the

emergency room be of a participating hospital. There is no factual

issue about whether the defendant is an emergency room of a

hospital -- it is not. The fact that the CDT receives Medicare

funds does not make it an emergency room of a hospital. 

Congress attempted to solve one problem -- to stop the

dumping of indigent patients by hospital emergency rooms -- and

chose language to effectuate its ends. That type of problem is not

presented by the facts of this case. It is up to Congress, if it

so wishes, to extend the protection of EMTALA to other situations.

It has not chosen to do so.

The denial of summary judgment to the defendants is

reversed and the federal claims are ordered dismissed with

prejudice. There being no basis for federal jurisdiction

otherwise, the district court is directed to dismiss the Puerto

Rican law claims without prejudice. No costs are awarded.