i i i i i i



### OPIN ION No
. 04 -0 9- 00 54 6- CV SAN ANTONIO EXTE NDED MEDICA L CARE, INC . D /B /A Me d M art , Appellant
v . Ruben VA SQU EZ , I ndividually , and as A dminist rator of the Estate of

Ruben Vasque z, J r., Dec ease d, and Or alia Va squez, J oe Ji menez, and Rosa Ward, Appellee s Fr om the 150th J udicial District Court, Be x ar County , Texas

Trial Court No. 2008-CI -20411 Honora ble Andy Mireles, Judge Pre siding OP INION ON AP P ELL EES ’ MOTION F OR REHEARING Opinion by : Phy lis J . Speedlin, J ustice Sitt ing: Catherine Stone, Chief Justice

Kar en Ang elini, J ustice Phy lis J . Speedlin, J ustice Deliver ed and F iled: May 26, 2010 REVERSED AND REMANDED The motion for re hear ing f i l ed by appellee s, Ruben Vasque z, indi vidually and as administrator of the E state of Ruben Vasque z, Jr., decea sed, and O ralia V asquez, J oe Ji menez, and Rosa Ward, is g rante d. This c ourt’s opinion a nd judgme nt dated F ebrua ry 3, 2010, are withdrawn, and this opinion and judgme nt are substitut ed.04
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- 2- I n this int erloc utory

a ppeal, San Antonio Extended Medica l Care, Inc. d/b/a Med Ma rt (“Me d Mart”) challeng es the trial c ourt’s orde r deny in g i t s m o t i o n to dismi ss filed pursuant to sec tion 74.351(a) of the Te x as Civil P rac tice and Re m ed i es Code. T EX . C IV . P R AC . & R EM . C ODE ANN . § 74.351(a) (Ve rnon Supp. 2009)
. Be cause we conclude the trial court err ed in f i n d i n g t h at Med Mart did not meet the de finition of a hea lth care provider, we reve rse the judgme nt of the trial cour

t and re mand the ca

use to the trial cour

t for fur ther proc eeding s. B ACKG ROUND O nA p r i l 7 , 2 0 0 8 , R

u b e n V a s qu e z , J r . ( “ M r . V a s qu e z ” ) u n d e r w e n ta t r a c h e o s t o m y. T e nd a ys afte r the surg ery , he was discharg ed from the hospital under doctor’s or ders to re ceive home oxy g en the ra py and tr a c he a c are . Me d Mar t del ive re d two oxy g e n ta nk s to Mr . V a sq

ue z’s ho me on

Ap ri l 17, 2 0 0 8
. T h e f

o ll o w in g d ay , M r . V a s qu e z’ s w if e c a ll e d M e d M art a n d in f o r me d th e m t h a t h er husband wa s running low on ox y g en. She ag ain i nformed Med Mart that the oxy g en supply was low on April 19, but another delivery was not ma de. L ater that day , Mr. Vasque z became unc onscious and wa s transported to the hospital by EMS. He died the ne x t day
. There afte r, on Dec ember

9, 2008, Ruben Vasque z, indi vidually , and as a dminist rator of the Estate of Rube n Va s q u ez, J r., dec ease d, and Or alia Va squez, J oe Ji menez, and Rosa Ward (c oll e c tiv e ly , “ Va sq

ue z”) su e d M e d M art

a lle g ing , amon g oth e r c la ims , th a t Mr . V a sq ue z’s de a th
was pr oximate ly

c a us e d b y the ne g lig e nt a c ts a

nd /or omi ssi on s o f M e d M art , in c lud ing : f a ili ngto pr ov ide a de qu a te oxy g e n ta nk s a s o rd e re d; f

a ili ngto r e sp on d to re qu e sts by Mr
. Va sq ue z’s fa mil y for a n adequa te oxy g en supply ; failing to insti tute safe g uards to i n s u re that patients such as Mr. Vasque z would alway s have a n adequate supply of medical supplies, inc luding ox y g en; and f ailing to provide an a dequate ox y g en supply as orde red by

his treating doctors.04
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- 3- On May 14 , 200 9, Me d M art fi le d a mot ion to d ism iss c la imi ngVa sq ue z fa ile d to se rv e his 120-day expert repor

t a s require d by section 74.351(a) of the Texas Civil Practice an d R em ed i es Code. See T EX . C IV . P R AC . & R EM . C ODE ANN . § 74.351(a) . Vasque z filed a motion to strike the motion to di smiss and a response to the motion to di smiss cl ai m i ng that he is not subject to the require ments of sec tion 74.351 because he did not asse rt a health ca re liability

claim ag ainst Med Mart and be cause Med Mar t is not a health ca

re pr ovider. Alter

natively , Vasque z arg ued in the motions t hat he c omplied with section 74.351 by filing a n au t o psy repor t attache d to a Sto we rs demand letter

within the 120-day

expert repor

t deadline a

nd that the re port was not objec ted to by Med Mart. The trial cour t denied the motion to dismi ss for fa ilure to file an e x pert re port without
makin g fi nd ing s of fa c t or c on c lus ion s of law, bu t or a lly state d that the e vid e nc e did no t de mon str a te Med Mart to be a health car e provider. The trial court’s order specific ally

stated that “[t] he Court makes no rulingon Plaintiff’s Motion to S trike De fenda nt’s Motion to Dism iss.” S TA N D A R D O F R E VI E W AND A PP LI C A BLE L AW We g e ne ra lly

re vie w a tr ia l c ourt ’s or de r g ra

nti nga mot ion to dis mis s fo r fa ilure to t ime ly file a section 74.351(a) expert repor t under a n abuse of discretion standa

rd. Pedroza v. Toscano , 293 S .W.3d 66 5, 66 6 ( Te x. Ap p. —Sa n A nto nio 20 09 , n o p e t.) ; H o lg u in v . La r e d

o R e g ’ l M e d

. Ce ntr., L.P. , 256 S.W .3d 349, 352 (Tex. App.—San Antonio 2008, no pet.). Howeve r, w h en the issue prese nted re quires a statutory interpre tation or a de termination of whe ther Chapter 74 applies to a claim, i.e. , questions of law, we use a de novo standard of revie w. Brown v. Villegas , 202 S.W .3d 80 3, 80 5 ( Te x. Ap p. —Sa

n A nto nio 20 06 , n o p e t.)
. Whe the r a cl a im i s a he a lthc are lia

bil ity c la im is a question of l aw. Inst. for W omen’ s Health, P.L.L.C . v. Im ad , N o . 0 4
- 0 5
- 0 0 5 5 5
- CV , 2 0 0 6 WL04
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- 4- 33 40 13 , * 1 ( Te x. Ap p. —Sa n A nto nio F e b. 15 , 20 06 , no pe t.) (m e m. o p. ); Lee v. B oothe , 235 S.W .3d 448, 451 (Tex. App.—Dallas 2007, pe t. denied). Section 74.351(a) provides that a health ca re liability

claimant must file an e x pert re port for
eac h phy sician or he alth car e provide r def endant within 120 day s afte r filing the claim. T EX . C IV . P R AC . & R EM . C ODE ANN . § 74.351(a) . I f the re quired repo rt has not bee n serve d by the 120-da

y deadline, on proper motion by a defe ndant, the trial court must dismiss the action with pre judice and
awa rd reasonable attorney ’s fees and court costs incurred by the def endant. Id. § 74.351(b) ( Ver non Supp. 2009). A “ he a lthc are lia

bil ity c la im” is d e fi ne d a s: [A] cause of action ag ainst a health car e provider or phy sician for treatment, la ck of tre a tm e n t, o r o th e r c la im e d d e p artu r e f r o m a c c e p te d s ta

n d ar d s o f me d ic a l c are , or he a lth c ar e , o r s a f

e t y o r p r o f

e s s i o n a l o r a d m i n i s t r a t i v e s e r v i c e s d i r e c t l y r e l a t e d to health ca re, w hich proxim ately

results in injury

to or death of a cla imant, whether the c la ima nt’ s c la im o r c a

us e of a c tio n s ound s in

tor t or c on tr a c t. T EX . C IV . P R AC . & R EM . C ODE ANN . § 74 .0 01 (a )( 13 ) ( Ve rn on 20 05 ). Whe the r a c la im f a lls wi thi n the def inition of a health ca

re liabili ty claim requires an ex amination of the “ essenc e” or “under ly ing nature” o f t he cla im. Di v e rsi c ar e Ge n. Pa rtn e r, In c . v . R ub io , 185 S.W .3d 842, 851 (Tex. 2005); Ho lgu in , 2 5 6 S
. W
. 3 d at 352. “A c ause of action ag ainst a hea lth care provider is a health ca re liability claim . . . if it is based on a claimed depar ture from an ac cepte d standard of medical c are , health care , or safety of t he patient, whe ther the a ction sounds in tort or contrac t.” Di v e rsi c ar e , 185 S.W .3d at 848. “A cause of ac tion alleg es a de parture from ac cepte d standards of medical c are or health ca re if the act or

omission complained o f is an insepar able pa rt of the r endition of medica l service s.” Id. The ne cessity of expert testimony

from a me dical or health care profe ssional may be
a fa c tor in d e te rm ini ngwh e the r a c la im i s an ins e pa

ra ble pa rt of the re nd iti on of

me dic a l or

he a lth04
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- 5- car e ser vices. Id. Ho we ve r, the fact th at ex per t te sti mony

may no t ul tim a te ly

be ne c e ssa

ry to
su p p o rta v e r d i c ta tt r i a l d o e s n o tn e c e s s ar i l y m e ant h e c l a i m i s n o t

a h e a l th c ar e l i a

b i l i t y c l a im. Mu rp hy v . R us se ll , 167 S.W .3d 835, 838 (Tex. 2005) (per curiam). D I S CUS S I ON On a pp e a l, M e d M art

a rgue s th e tr ia l c ou

rt a bu se d it s d isc re tio n in

de nyingits mot ion

to dismiss beca

use Vasque z asse rted a health car e liability claim and wa s theref ore r equire d to serve an expert re port. I n support, Med Mart asser ts that Vasque z’s claims for ne g lige nce ba sed on Med Mart ’s a lle g e d f

a ilure to f ur nis h a de qu a te oxy g e n to Mr
. Va sq ue z me e t a ll thr e e pr on g s of a he a lth
c are lia bil ity c la im. I t is un dis pu te d th a t V a sq ue z al le g e d th a t Me d M art c a us e d M r. Va sq

ue z’s de a th by fa ili ng to de liv e r oxy g e n; thu s, the thi rd e le me nt ne c e ssa ry to e sta bli sh a he a lth care l iab ili ty
c la im— that th e pla int if

f m us t a lle g e that th e d e f

e nd ant’ s a c tio n p ro xima te ly c a us e d in jur y to o r d e a th of a c laimant—has bee n sat isfied. T EX . C IV . P R AC . & R EM . C ODE ANN . § 74.001(a) (13). Acc ording ly , we must deter mine whether Med Mart is a he alth car e provide r, and, if so, w hether the claims asser

ted by Vasque z cla imed a depar ture from the acc epted standards of health ca re. See id. 1. Health C

are Provide r A hea lth care liability

claim is a ca

use of a ction ag ainst a hea lth care provider or phy sician. Id. A “ he a lthc are pr ov ide r” is d e fi ne d a s: [A] ny person, pa

rtners h i p , profe ssional association, cor poration, fa cility , or ins tit uti on du ly li cens e d, c e rt if

ie d, re g ist e re d, or

c ha rt e re d b y the State of

Te xas t o pr ov ide he a lthc are , in c lud ing : ( i) a re g ist e re d nurs e ; (i i) a de nti st; (i ii) a

po diatr ist ; (iv) a pha

rmac ist; (v ) a chiropra ctor; (vi) a n optometrist; or (vii) a hea lth care instit ution.04
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1 ... T he t erm “ heal t h care pro vi d er” al so i ncl ud es: “ (i ) a n o ff ic e r, d i rect o r, s hareho l d er, m em b er, pa rt ner, m anager, ow ner, or af

f i l i at e o f a he al t h c are p rovider o r p hy si ci an; a nd (i i ) an em p l o y ee, indep end ent c o nt ract o r, or agent o f a h e a lth c a re p ro v id e r o r p h ysic ia n a c ting in the c o u rs e a n d sc o p e o f t h e e m p lo ym e n t o r c o n tra c tu a l r e la tio n sh ip .” T EX . C IV . P RAC . & R EM . C O D E A NN . § 7 4 .0 0 1 (a )( 1 2 )( B ) (V e rn o n 2 0 0 5 ).

- 6- T EX . C IV . P R AC . & R EM . C ODE ANN . § 74.001(a) (12)( A) (Ve rnon 2005). 1 The list is not ex clusive. See Chris tus Health v. Beal , 240 S.W .3d 282, 286 (Tex. A pp.—Houston [1st Dist.] 2007, no pet.) (c i t i n g T EX . G OV ’ T C ODE ANN . § 31 1. 00 5( 13 ) ( Ve rn on 20 05 ), wh ic h p ro vid e s th a t “ inc lud ing ” is
a term of enlar g ement and not of limit ation). The statute define s “hea lth c are” a s “a n y ac t or tr e a tmen t pe rf

or me d o r f ur nis he d, or that sh ou ld h a ve be e n p e rf or me d o r f ur nis he d, by

any he a lth
car e provide r for , to, o r o n b eh al f of a patient during the patient’s medic al ca re, tre atment, or confine ment.” T EX . C IV . P R AC . & R EM . C ODE ANN . § 74.001(a) (10) ( Ver non 2005). At the hea ring on the motion to dismiss , Carlos Ba rre ra, Med Mart’s vice president, testified that Me d M art

is a c omp any

lic e ns e d b y

the Tex as Dep artme nt o f H e a lthand lic e ns e d a s a presc ription drug firm. B arr era further stated that oxy g en is a drug wh ich re quires a doc tor’s presc ription. I t is undisputed that Mr. Vasquez was prescribe d ox y g en by his treating phy sician, Dr. Mark W
. Hatch, who order ed that he be rele ased from the hospital and treated at home with oxy g en thera py . I t is li kewise undisputed that Me d Mart was the entity selec ted to pr ovide home hea lth care service s for Mr. V asquez. Phy sicians’ orde rs were faxed to Med Mart by the hospital. Med Mart contends that these attributes make it a he alth car e provide r. Va squez counters that Med Mar t cannot be a he a lthc are pr ov ide r be c a us e it is no t sp e c if

ic a lly lis te d a s su c h in

the statut e and

be c a us e it i s
mere ly licensed by

the State as a

distributor or manufa cture r, not as a he alth car e provide r. We ag ree that Med Mar

t qualifies a s a h ea lth care provider. T he re cord he re c ontains
e vid e nc e tha

t Me d M art

is l ic e ns e d b y

the Te xas D e pa

rtme nt o f S ta te He a lthServi ces as a04
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- 7- presc ription drug firm (manufactur er) and as a li cense d device firm (distributor and manuf actur er)
. Fur ther, the r ecor d contains testimony from Med Ma

rt’s vice president, who stated th a t a presc ription drug firm lice n s e i s t he same license he ld by pharma cies. Unlike in Brown v. Villegas , wher e we held that the alleg ed hea lth care provider f ailed to prove its status as such by not inc luding proof that it was “lice nsed, ce rtified, re g istered, or char tere d by the State of Texas to provide hea lth care ,” Med Mart met its burde n of establishing licensure by the State. Se e Br own , 202 S.W .3d at 806. Vasque z contends that the e vidence here mere ly demonstrates Me d Mart held a license to distribu te and manufa cture drug s—not to provide health car e—our r eadingof the statute lea ds us to conclude that such license s meet the de finition of a hea lth care provider. Se e Pe dr oz a , 293 S.W .3d at 668 (noting that to asce rtai n t h e l egi s lative intent of a statute, w e beg in with its plain lang uag e); Ma rk s v . S t. Luke’s Episcopal Hosp. , No. 07-0783, 2 0 0 9 WL 2 6 6 7 8 0 1 , a t * 3 ( T e x. A u g . 2 8 , 2 0 0 9 ) (“ When interpre ting a

statute, we r ead w ords and phrases in contex t and construe them acc ording to the rules of g ra mma r a nd com mo n us ag e .” ). Th e statut e me re ly re qu ir e s th a t th e pr ov ide r b e lic e ns e d to “provide health ca

re.” T EX . C IV . P R AC . & R EM . C ODE ANN . § 74.001(a) (12)( A). “ Hea lth care means any act or treatment perfor

med or fur

nished, or that should have been pe rfor med or furnished, by

any health ca re pr ovider for, to, or on behalf of a patient during the patient’s medical car e, tre atment, or confine ment.” T EX . C IV . P R AC . & R EM . C ODE ANN . § 74.001(a) (10). As will be discussed below, Med Mar t supplied presc ription-order ed oxy g en ther apy to Mr. Vasque z. At a minim um, the de livery of

the oxy g e n c on sti tut e d a n “ a c t” pe rf

or me d b y Me d M art

fo r M r. Va sq

ue z duri nghis treatment. See id. Even thoug h the oxy g en wa s delivere d to Mr . Vasque z’s home, he was r elea sed from the hospital u n der doc tor’s orde rs to rec eive home oxy g en ther apy , without which he wa s incapa ble of bre athing
. See, e .g., Tesoro v. Alvarez , 281 S.W .3d 654 , 660 (Tex. App.—Corpus04
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- 8- Christi 2009, no pet.) (location at which health car e is perfor med or fur

nished is not determinative of whether claim constitutes a health car e liability claim). Acc ording ly , we hold that on this rec ord there was sufficient evidence to prove Med Mart’s status as a health ca re pr ovider. We next ex amine whether Vasque z’s claims alleg ed a claimed departure from the acc epted standards of he alth car e.

2. Cla imed

De pa rturefrom Ac c e

pte d St and ards of He alt h Care To establish a he alth car e liability claim, the ac t or omissi o n compl ained of must be an insepara ble par t of the re ndition of health ca re se rvice s. S

e e D i v e r s i c ar e , 1 8 5 S
. W .3d at 848; Ga rla nd Cm ty
. Ho sp . v . R os e , 156 S.W .3d 541, 544 (Tex. 2004). A fa ctor in consider ing w hether
a ca use of a ction is an i n s ep ar able pa rt of the r endition of hea lth care service s is whether e x pert testimony from a me dical or health care profe ssional is nece ssary to prove a claim. Di v e rsi c ar e , 185 S.W. 3d at 8 48 ; Espinosa v. Baptist Health Sys ., No. 04-05-00131- CV, 2006 WL 2871262, at *1 (Tex. App.—San Antonio O ct. 11, 2006, pet. denie d) (mem. op.) . Her e, Va squez alleg ed that Mr. Va sq ue z’s de a th w a s p ro xima tely caus e d b y the ne g lig e nt a c ts a

nd /or omi ssi on s o f M e d M a rt , including: f

ailing to provide adequate ox y g en tanks as ordered; failing to re spond to requests by Mr. Va sq ue z’s fa mil y fo r a n a de qu a te oxy g e n s up ply ; f a ili ngto i ns tit

ute sa fe g ua

rd s to ins ur e that patie nts such as Mr. Vasque z would alway s have an adequate supply of medica l supplies, including oxy g en; and fa iling to provide a

n adequate oxy g en supply as ordered by his treating doctors. On appe al, Med Mart conte nds that Vasquez’s cla ims are insepara bly and inex tricably linked to the rendition of Mr. Vasque z’s health car e bec ause his death is alleg ed to have been c aused, at least in part, b y Med Mart’s f ailure to provide him with ox y g en which w as pre scribed by his d o ct o r as post-operative treatment. I n response , Vasque z maintains t hat Med Mar t was mere ly

deliveringox y g en to Mr.04
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- 9- Vasque z and was not requir ed to re main at his bedside as the ox y g en wa s used; ther ef ore, the delivery of oxy g en tanks c annot be a n insepara

bl e p ar t of the re ndition of medical or he alth car e
se rv ic e s. The fa cts of this case are simil ar to those in Valdez v. L o p ez Health System s , wher e the plaintiff’s daug hter died a fter a home hea lth care servi ce wo rk er removed the por table suction machine r equire d for he r survival. Valdez v. Lopez He alth Sys., Inc. , No. 04 -0 4-00023-CV, 2005 WL 1629803, at *1 (Te x . App.—San Antonio J uly 13, 2005, no pet.) (me m. op.). The plaintiff
a lle g e d th a t th e ho me he a lthse rv ic e wa s n e g lig e nt i n f a ili ngto p ro vid e ne c e ssa

ry m e d i c a l e q

u ipm e nt. Id. Th is c ourt

he ld t hat th e pla int if

f’ s c la ims we re g ov e rn e d b y se c tio n 7 4. 35 1 be c a

us e in or de r t o
e sta bli shlia bil ity , th e pla int if

f w ou ld h a ve to p ro ve the sta nd ard of c are a

pp lic a ble to hom e he a lth
car e provide rs and then showthat the standar d was bre ache d. Id. a t *2 . Si mi larly , in or de r t o establish that M ed M ar t was ne g lige nt in failing to provide nece ssary medical e quipment to Mr. Vasque z, Vasquez would have to prove that the standa rd of c are applicable to a hea lth care provider require d Med Mart to de liver oxy g en and that Med Mart bre ache d that standard. T hus, Vasquez has complained of

acts or omissions that occur red dur ing Mr . Vasque z’s treatment by Med Mar t. See Ro se , 156 S.W .3d at 544. Acc ording ly , we conclude Vasque z’s claims ag ainst Med Mart a sserted an alleg ed depa

rture f rom the ac cepte d standards of health ca re. This conclusion is further

bolstered by

the fa ct that expert testimony will be require d to prove Vasque z’s cl ai m s . See id. (noting that one conside ration in deter mining whe ther a lleg ed ac t or omission i s insepara

ble par t of hea lth care is proving claim would require specia liz ed knowledg e of
an e xpe rt ). As Me d M art no te s, Va sq ue z a lle g e d mor e tha

n a me re fa ilure to d e liv e r o xy g e n. I t is undisputed that Med Mart delivere d two ox y g en tanks to Mr. Vasque z. One was ha lf full and the04
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- 10- other wa s a quar

ter full. The Med Mar

t technician se t the flow rate of the t an k s at t wo l i t ers pe r minute. The question, there fore , is w hether an adequate supply of ox y g en was de livered. Me d Mart argues that it is not withi n the common knowledg e of the gene ral public to know whe ther the c orre ct flow rate was se t or whethe r there was a n adequate supply

of oxy g en deliver ed in the first instance
. Se e Di v e rsi c ar e , 1 85 S.W. 3d a t 84 8, 85 1. We a g re e . E x pe rt te sti mony

is r e qu ir e d to e sta

bli sh whether the oxy g en tanks we re se t at the corr ect flow level or whether an adequate supply of oxy g en was de livered to Mr. Vasquez. Such information i s not within the common knowledge of the g ener al public. Se e Ro se , 156 S.W .3d at 544; Imad , 2006 WL 334013, at *3. C ONCL US I ON Ba sed on the re asons stated a bove, we conclude Vasque z was subject to the re quirements of
se c tio n 7 4. 35 1 b e c a

us e Va sq ue z’s su it a sse rt s a he a lth c are lia bil ity c la im a g a ins t Me d M art , a he a lth
car e provide r. Se e Ro se , 1 56 S.W. 3d a t 54 6; Ho lgu in , 256 S.W .32d at 3 5 3
. T h e trial court e rre d when it denied Med Mart’s Motion to Dismiss on the basis that Med Mar t did not meet the statutory definition of a health car e provider. Be cause of the trial court’ s err oneous conc lusion on thi s issue, it never considere d Med Mart’s Motion to Dis miss or Vasquez’s re sponsive Motion to S trike Med Mart’s Motion to Dismiss. According ly , we r ever se the trial c ourt’s orde r d enying Me d Mart’s motion to di smiss, and remand the c ause to the tria l court for further proce eding s. Phy lis J . Speedlin, J ustice