Case Name: ADVENTIST HEALTH SYSTEM/SUNBELT, INC., etc., Appellant, v. FLORIDA BIRTH-RELATED NEUROLOGICAL INJURY etc., et al., Appellees
Court: Florida District Court of Appeal
Jurisdiction: Florida
Decision Date: 2004-01-02
Citations: 865 So. 2d 561
Docket Number: No. 5D02-892
Parties: ADVENTIST HEALTH SYSTEM/SUNBELT, INC., etc., Appellant, v. FLORIDA BIRTH-RELATED NEUROLOGICAL INJURY etc., et al., Appellees.
Judges: PETERSON, THOMPSON, PALMER, ORFINGER and MONACO, JJ., concur.
Reporter: Southern Reporter, Second Series
Volume: 865
Pages: 561–579

Head Matter:
ADVENTIST HEALTH SYSTEM/SUNBELT, INC., etc., Appellant, v. FLORIDA BIRTH-RELATED NEUROLOGICAL INJURY etc., et al., Appellees.
No. 5D02-892.
District Court of Appeal of Florida, Fifth District.
Jan. 2, 2004.
Rehearing Denied Feb. 18, 2004.
Robert A. Hannah, Christopher C. Curry and Robin D. Black, of Hannah, Estes & Ingram, P.A., Orlando, and Raymond T. Elligett, Jr., of Sehropp, Buell & Elligett, P.A., Tampa, for Appellant.
Thomas E. Dukes, III, of McEwan, Martinez & Dukes, P.A., Orlando, for In-tervenors, Michael Geiling, D.O. and Mid-Florida OB/GYN Specialists, Inc.
Pierre J. Seacord and Gregory M. Krak, of Ringer, Henry, Buckley & Seacord, P.A., Orlando, for Intervenor, Juan Ravelo, M.D.
John Elliott Leighton, Patricia M. Kennedy, of Leesfield, Leighton, Rubio, Mah-food & Boyers, P.A., and Jay M. Levy, of Jay M. Levy, P.A., Miami, and Lora A. Dunlap, of Fisher, Rushmer, Werrenrath, Dickson, Talley & Dunlap, P.A., Orlando, for Appellees, Sandra Shoaf and James Shoaf.
Wilbur E. Brewton and Kelly B. Plante, of Roetzel & Andress, L.P., Tallahassee, for Appellee, Florida Birth-Related Neurological Injury Compensation Association.

Opinion:
ON MOTION FOR REHEARING EN BANC
GRIFFIN, J.
Upon motion of appellees, we have elected to rehear this case en banc. After consideration of the briefs and en banc oral argument, we withdraw the prior panel opinion and issue the following en banc opinion in its stead.
The Adventist Health System/Sunbelt, Inc., d/b/a Florida Hospital-Altamonte ["Florida Hospital"], and intervenors, Michael Geiling, D.O., Juan Ravelo, M.D., and Mid-Florida OB/GYN Specialists, Inc., appeal an order issuéd by an administrative law judge ["ALJ"] finding that Raven Shoaf ["Raven"] was not subject to compensation under the Florida Birth-Related Neurological Injury Compensation Plan ["the plan"], because she was not permanently and substantially "mentally impaired" within the meaning of the plan. Appellants contend that, based on certain undisputed facts, she was permanently and substantially mentally impaired as a matter of law. We disagree and affirm.
Raven was born at Florida Hospital in Altamonte Springs, Florida, on November 28, 1997. She was deprived of oxygen during birth and sustained serious injuries. Her parents, Sandra and James Shoaf ["the Shoafs"], filed an action for medical negligence in Seminole County circuit court against Florida Hospital, as well as Geiling and Ravelo, the two physicians who provided obstetrical services to Raven's mother, and Mid-Florida OB/GYN Specialists, Inc. Both obstetricians were "participating physicians" under the plan and the hospital was a participating hospital, but the Shoafs did not file or pursue a claim for benefits under the plan.
The Florida Birth-Related Neurological Injury Compensation Association ["NICA"] intervened in the circuit court action, claiming that Raven's injuries were subject to the plan. The circuit court abated the action and required the Shoafs to file a petition with the Division of Administrative Hearings to resolve whether Raven was covered by the plan. The NICA statute defines "birth-related neurological injury" to mean an injury which, among other things, renders the infant both "permanently and substantially mentally and physically impaired." § 766.302(2), Fla. Stat. (1995). (Emphasis added.) The Shoafs' position was that Raven did not meet the criteria for coverage under the plan because, although she had suffered significant physical impairments, she had not sustained a permanent and substantial mental impairment.
A two-day hearing was held before an ALJ, principally to resolve the issue of mental impairment. The evidence adduced at the hearing showed that Raven had significant and severe physical injuries due to oxygen deprivation. It was essentially undisputed that she has cerebral palsy, which refers to a group of motor disorders caused by an injury to the developing brain. Also, Raven's CAT scans and MRI's showed that she had sustained various permanent injuries to her brain. Her imaging studies show that she has damage to both sides of the basal ganglia and thalamus. There was also damage to the white matter surrounding the basal ganglia (which acts as insulation), the hippo-campi, both frontal lobes, both parietal lobes, the corpus callosum, and the cerebral cortex. Most witnesses testified these injuries were diffuse (Le.seleetive), as opposed to global in nature. Her physical injuries include both spasticity and stiffness; when she tries to move, her body goes in the opposite direction and she gets posturing, as well as a wiggly movement. She is unable to walk or talk and has problems holding her head up and directing her gaze. She can crawl or sit up only with assistance. She cannot reach out and hold objects. She is unable to eat by mouth and must wear a diaper. Statistically, a little less than one-half of the children who present with cerebral palsy, as Raven does, are not cognitively impaired.
The dispute in this case concerns whether Raven has a permanent and substantial "mental impairment" in addition to the cerebral palsy. The parents presented several witnesses, including several physicians, Raven's speech therapist and an occupational therapist, who testified that, despite her physical impairments and the damage shown on the scans, Raven is of normal or above-average intelligence, and can demonstrate that intelligence in many ways. These expert witnesses all agreed that Raven was not "mentally impaired" as a result of her injuries. One witness even testified that Raven may eventually be able to attend classes in a normal classroom, although she may have to have substantial assistance with such things as going to the bathroom and using her feeding tube. These physicians explained that some children with abnormal MRI's and scans can still be very bright, in part due to "plasticity," which refers to the ability of the brain of a young child to rewire itself to take on functions that normally would have been assigned to another part of the brain. Witnesses testifying that Raven had normal cognitive functioning attributed her difficulties in communication to her physical problems. This testimony is outlined in detail in the final order in support of the ALJ's finding that Raven was not "permanently and substantially mentally impaired" within the meaning of the plan. Many of these witnesses had contact with Raven on an ongoing basis, a fact important to the ALJ.
By contrast, witnesses presented by NICA and the intervenors testified that Raven has an I.Q. as low as twenty or thirty due to her injuries and that she has no understanding of the world around her. One of these experts even characterized the belief that Raven was responsive as being nothing more than her parents' wishful thinking.
In the ALJ's forty-nine page order exhaustively reviewing the evidence presented by the parties, along with the reports presented by their experts, the ALJ explained his evaluation of the evidence presented to him. He found that Dr. Du-chowny, the pediatric neurologist who opined that Raven had no awareness of the world around her, had examined Raven only for one-half an hour when she was three-and-one-quarter years of age, and his findings conflicted with observations made by her parents. Dr. Waters, who found Raven's cognitive deficit "significantly large," also performed a relatively cursory examination, but even she had detailed in her report some responses made by Raven to various stimuli and testing. By contrast, Dr. Brunstrom, who had found that Raven was "cognitively intact," had examined her on three occasions for a total of nearly eight hours, and the judge quoted extensively from the report, detailing Raven's responses. He also noted that two other pediatricians with special qualifications in child neurology and a board certified clinical neuropsychologist, expressed opinions consistent with Dr. Brun-strom's and each had examined Raven for approximately two hours. The judge concluded that those witnesses who testified that Raven was cognitively intact were "well qualified and positioned" to evaluate Raven, while those who testified on behalf of the intervenors were not. Based on his evaluations of the evidence, the judge concluded that NICA and the intervenors had failed to sustain their burden of proving that Raven is mentally impaired within the meaning of the plan:
The medical records and other proof, including the testimony of the various healthcare providers and the videos offered by the parties have been carefully considered. So considered, it must be resolved that the proof does not permit a conclusion to be drawn, with any sense of confidence, that, more likely than not, Raven is permanently and substantially mentally impaired.
Notwithstanding the evidence adduced at the hearing and the ALJ's factual findings, appellants' position, simply put, is that Raven was permanently and substantially mentally impaired as a matter of law. For this contention, they rely on Florida Birth-Related Neurological Injury Compensation Ass'n v. Florida Div. of Admin. Hearings, 686 So.2d 1349, 1354 (Fla.1997) [the "Birnie " decision].
The Birnie case involved injuries apparently similar to those sustained by Raven in this case. As a result of birth-related events causing oxygen deprivation, Eric Birnie suffered a focal injury to the basal ganglia, an area of the brain which aids the body in performing "physical functions." Despite severe physical limitations, testing indicated that Eric was average or even above average in his cognitive skills. Eric's parents nonetheless sought compensation under the plan, claiming that he was "mentally impaired" within the meaning of section 766.302(2), Florida Statutes (1991). NICA denied coverage, and a hearing was held to determine whether Eric's injury was covered by the plan. Key among the findings of fact made by the Bimie ALJ was:
44. Erie is indisputably permanently and substantially physically impaired. Respondent contends, however, that Eric and his parents are not entitled to compensation under the NICA Plan because he is not substantially mentally impaired. This issue is addressed in more detail in the Conclusions of Law below. As noted above, Eric's condition is the result of damage to his brain. As a direct result of his injury, Eric will not be able to communicate, attend school or otherwise learn and' develop intellectually without substantial accommodation. His social and vocational development have unquestionably been significantly impaired.
Id. at 1352-1353. In Birnie, the hearing officer rejected the argument that mental impairment should be equated with cognitive functioning. He instead focused on the special accommodations necessary for Eric to develop intellectually and the social and vocational limitations on the child as a result of his injury. The judge found:
61. In sum, it is concluded that, as a direct result of his brain injury and consequent physical limitations, Eric will not be able to translate his cognitive capabilities into adequate learning in a normal manner. Moreover, as a direct consequence of his injuries, Eric's social and vocational development have been drastically impaired. Consequently, it is concluded that Eric is permanently and substantially mentally and physically impaired and that Eric has suffered a "birth-related neurological injury," within the meaning of Section 766.302(2), Florida Statutes. Accordingly, the subject claim is compensable under the NICA Plan. Sections 766.302(2), 766.309(2), and 766.31(1), Florida Statutes. This interpretation furthers the legislative intent to provide compensation to a limited class of catastrophically injured infants on a no-fault basis to help alleviate the malpractice insurance crisis facing physicians practicing obstetrics.
Id. at 1353 (footnote omitted) (emphasis added). Additional findings were made by the ALJ which were omitted from the supreme court's opinion, but which are available to this court because the Bimie case was initially decided here. See Florida Birth-Related Neurological Injury Comp. Ass'n v. Florida Div. of Admin. Hearings, 664 So.2d 1016 (Fla. 5th DCA 1995). The ALJ expressed doubt about the reliability of intelligence tests given to children under the age of five (Eric was three years and ten months old when tested), especially when the child has physical limitations as severe as Eric's. He further noted that "it is impossible to determine whether and to what extent Eric's level of intelligence and/or his perceptual and processing abilities have been reduced by the injury to his brain, regardless of what his test scores show at this time." He determined that the results of the intelligence tests should not be given undue weight in deciding whether Eric is substantially mentally impaired. He explained: "Instead, the nature, extent and implications of Eric's injury should all be taken into account in determining whether Eric has been permanently and substantially physically and mentally impaired." He also relied on his own meeting with Eric:
60. Eric was present and testified at the hearing in this matter. While he appears to be a happy, charming little boy, it is extremely difficult to understand any of his utterances and he has to pause to gather his thoughts and/or his strength while he is attempting to communicate. Eric has virtually no independent mobility. It is obvious that Eric has suffered a catastrophic injury. The severity of Eric's physical limitations will greatly restrict his ability to interact with others, to attend school and to otherwise develop in a normal manner. As a consequence, Eric's ability to achieve the milestones and develop the skills that would enable him to be socially, educationally and intellectually competitive has certainly been impaired. Without question, his occupational opportunities have been drastically affected. The contention that Eric is not "mentally impaired" ignores the totality and pervasiveness of his injury. The results of an intelligence test are only a limited measure of one aspect of mental functioning. Such results should not be given conclusive weight over a consideration of the totality of the impact of the injury on the victim. While Eric's IQ test may be within normal ranges under certain special conditions, Eric will never be able to test within the "normal" range if the tests are administered in a "normal" manner nor will he be able to develop and use his cognitive ability in a normal way.
The Bimie ALJ then noted that the term "mentally impaired" is not defined in the NICA statute nor is there any delineation of the conditions this term encompasses. He relied on cases discussing "mental impairment" or "mental inability," that suggested various meanings, including mental weakness, deterioration or damage or any condition which weakens, diminishes, restricts or otherwise damages an individual's mental activity, not limited solely to intellectual or educational attainment.
He concluded that the term "mentally impaired" should be interpreted in accordance with the purpose of the NICA legislation after consideration of all the circumstances involved in a case. His evaluation of all the evidence presented to him caused him to conclude that Eric was "permanently and substantially mentally impaired."
NICA appealed the determination that Eric was entitled to compensation. This court affirmed, concluding that the plan did not intend to differentiate between mental and physical impairment, but was intended to cover an infant if there was substantial impairment, either mental or physical. Id. at 1021.
NICA then appealed to the Supreme Court of Florida, which rejected this court's interpretation of the plan, and' found that the plain language of the statute required both mental and physical impairment. At the close of the opinion, the Supreme Court of Florida approved the hearing officer's conclusion that Eric had sustained both mental and physical impairment within the meaning of the plan, briefly explaining:
[ 5] We are left with the hearing officer's finding — which is properly predicated on a reading of the statute in the conjunctive — that Eric Bernie is "permanently and substantially mentally and physically impaired and . has suffered a 'birth-related neurological injury' within the meaning of section 766.302(2)." Having thoroughly reviewed the record and the hearing officer's final order, ^ye conclude that it is supported by competent and substantial evidence. Consequently, we disapprove the opinion below to the extent that it misconstrues the plain language of the statute, but approve the result, and direct that the case be remanded to DOAH for a determination of the amount of compensation Eric is entitled to under the NICA Plan.
686 So.2d at 1356.
Appellants construe the above-quoted passage from the Bimie decision to create the definition of "substantial mental impairment" as this phrase is used in NICA. According to appellants: "The Bir-nie decision added to the definition of substantial mental impairment by effectively adding a requirement that the child be able to translate any cognitive capabilities into adequate learning in a 'normal manner.' " It is apparent, however, that the Bimie court did not define or redefine "substantial mental impairment." They simply said that the decision of the ALJ was supported by competent evidence. All this language in Bimie suggests is that, under NICA, the identification of a substantial mental impairment may include not only significant cognitive deficiencies but can include, in a proper case, additional circumstances such as significant barriers to learning and social development.
Appellants urge that, although Raven's brain injuries have not resulted in cognitive impairment, in the sense that they do prevent Raven from learning or thinking, they must, as a matter of law, constitute a "mental impairment" within the meaning of the plan because, like Eric Birnie, she will require substantial accommodation in order to translate normal cognitive capabilities into learning. Apart from the evidence adduced and the findings made in this case, there are many other problems with this position. First, as a definition, it is not the plain and ordinary meaning of the undefined statutory term. The Bimie court made clear that the plain and ordinary meaning of these terms should be applied. 686 So.2d at 1354. Second, it violates the definitional framework approved by the supreme court in Bimie:
'The Statute is written in the conjunctive and can only be interpreted to require permanent and substantial impairment that has both physical and mental elements.'
Id. at 1356. To say that physical disabilities that impede the cognitive and social development of a child alone are enough to constitute a mental impairment violates the dichotomy identified by the high court in Bimie. If this were the true definition of "substantial mental impairment," then seemingly most children with cerebral palsy would be classifiable as "substantially mentally impaired," although the evidence indicates that cerebral palsy and mental defect are two separate injuries. There was expert testimony that children with oxygen deprivation injuries "can be physically disabled, yet be intellectually preserved." Cerebral palsy is a motor injury which occurs when the circuits in the brain that control movement are damaged, while cognitive injury or impairment occurs when circuits relating to memory or learning are impaired. Furthermore, according to the testimony, oxygen deprivation or hypoxia first attacks those areas of the brain which control motor function, and only secondarily results in damage to mental function.
The Shoafs point out that the interpretation of "mental impairment" urged by appellants in this case contravenes the principle that:
because the [NICA] Plan, like the Worker's Compensation Act, is a statutory substitute for common law rights and liabilities, it should be strictly construed to include only those subjects clearly embraced within its terms . [and] a legal representative of an infant should be free to pursue common law remedies for damages resulting in an injury not encompassed within the express provisions of the Plan.
686 So.2d at 1354, quoting Humana of Florida, Inc. v. McKaughan, 652 So.2d 852, 859 (Fla. 2d DCA 1995) (citation omitted). Because the legislature chose not to define the terms used in the test for NICA qualification, these terms are to be given their ordinary meanings. Id. The legislature left the application of the terms they used to the administrative law judges designated by statute to hear these claims and to apply the expertise they develop in carrying out this task to determine from the evidence adduced in each case whether the test for NICA is met.
The dissent expresses concern that our decision condones different outcomes on identical facts. First, nothing suggests that the facts of these two cases are identical. Eric Birnie and Raven Shoaf are two very different individuals. There are certainly similarities in the injury and in the consequent physical impairments. Most important, for purposes of our decision, the Shoafs acknowledge that there was testimony below that, like Eric Birnie, Raven's physical impairments will require accommodation for verbal communication, schooling and other life activities, even though the testimony was conflicting as to degree.
Courts have always recognized that different juries may reach a different result on similar facts. See e.g., Middleton v. Evatt, 855 F.Supp. 837, 840 (D.S.C.1994). It is common for us to see, for example, that juries have awarded significantly different sums for apparently identical injuries. We similarly see different outcomes when the fact finder is asked to determine whether a particular injury is "permanent" or "not permanent." These differences arise not because we have an "unprincipled, incoherent system" but because such differences can arise in a principled and coherent system where every individual is guaranteed an opportunity to lay his own case before an impartial arbiter of the facts. In most cases, this is a jury. In cases such as the one before us, the ALJ, as fact finder, brings his own background, training, experience and expertise to the task of weighing and evaluating very sophisticated evidence. The child's advocate likewise brings his own communication and strategic skills to the fact-finding process; and finally, the evidence in each case will vary in its power to persuade. This will be especially true in cases where the opinions of experts are considered. In Birnie, for example, the ALJ did not appear to be persuaded by the evidence offered to him by NICA of the level of Eric's intellect and ability to function. We don't know why; perhaps the evidence wasn't very good, or perhaps it wasn't well presented. In any event, it is clear that other facts, and other evidence, including his personal encounter with Eric, persuaded Eric's ALJ to come to a different conclusion than the ALJ who heard the evidence offered by the Shoafs. In each case, the ALJ appears to have attempted to apply the plain and ordinary meaning of the term "substantial mental impairment" to his evaluation of the evidence. The term is broad enough to encompass more than just damage to cognitive capacity, contrary to appellees' argument, and more than merely the inability to "translate cognitive capabilities into adequate learning in the normal manner" or "impairment of social and vocational development," as urged by appellants. Both the ALJ in the Birnie case and the ALJ in this case appear to have understood this and to have done their job conscientiously.
Finally, as judges, we learn, early on, that there are always fact situations at the margins where it is very difficult to determine the side of a line on which a particular decision will fall. That is one reason why our review is limited to whether the decision was supported by substantial competent evidence.
The Birnie ALJ considered the evidence given to him, weighed its credibility and reached a decision about Eric. Likewise, the ALJ in this case considered the evidence given to him, weighed its credibility and made a decision about Raven. Each judge weighed the evidence he was given and reached a result that the evidence supported. The fact that they were different results, even though certain of the evidence was similar, does not make one decision wrong and the other right. Evidence that can support a fact-finder's conclusion is far different from evidence that compels a particular conclusion.
In affirming the ALJ's decision in this case, we have done exactly what the high court did in Birnie. We have looked to see whether competent evidence supports the ALJ's decision. Otherwise, Raven Shoaf and all other similarly injured Flori da children will have no right to an individualized determination of mental impairment, but will be bound by the work of the lawyers for Eric Birnie, whose goal was to show that he was mentally impaired. Appellants bore the burden of persuasion in this case that Raven was "substantially mentally impaired" and its evidence was not persuasive to the finder of fact.
AFFIRMED.
PETERSON, THOMPSON, PALMER, ORFINGER and MONACO, JJ., concur.
SAWAYA, C.J., concurs and concurs specially, with opinion, in which PALMER, J., concurs.
TORPY, J., concurs specially, with opinion.
SHARP, W., J., dissents, with opinion.
PLEUS, J., dissents, with opinion, in which SHARP, W., J., concurs.
.Section 766.302(2), Florida Statutes (1995), in its entirety provides:
"Birth-related neurological injury" means injury to the brain or spinal cord of a live infant weighing at least 2,500 grams at birth caused by oxygen deprivation or mechanical injury occurring in the course of labor, delivery, or resuscitation in the immediate postdeliveiy period in a hospital, which renders the infant permanently and substantially mentally and physically impaired. This definition shall apply to live births only and shall not include disability or death caused by genetic or congenital abnormality.
. The parties stipulated that Mrs. Shoaf was provided with notice of the plan by her obstetricians. The ALJ also found that proper notice was provided by the hospital.
. One witness described the difference in reference to New York City. Diffuse injuries occur when specific structures within the city of New York are destroyed, while global injury means all parts of the city sustain damage.
. Florida and Virginia appear to be the only two states which currently have such plans in place. In its original form, the Virginia statutes defined "birth-related neurological injury" to mean: "an injury that rendered the child nonambulatory, aphasic, incontinent, and in need of assistance in all phases of daily living." Gibson v. Riverside Hospital, Inc., 250 Va. 140, 458 S.E.2d 460, 462 (1995). The statute was amended in 1990, and again in 2003, to redefine a "birth-related neurological injury" to mean:
injury to the brain or spinal cord of an infant caused by the deprivation of oxygen or mechanical injury occurring in the course of labor, delivery or resuscitation in the immediate post-delivery period in a hospital which renders the infant permanently motorically disabled and (i) developmentally disabled or (ii) for infants sufficiently developed to be cognitively evaluated, cognitively disabled. In order to constitute a "birth-related neurological injury" within the meaning of this chapter, such disability shall cause the infant to be permanently in need of assistance in all activities of daily living.
Va.Code Ann. § 38.2-5001 (Michie 2003) (emphasis added).
. Appellees point out in their brief that Rule 4J 6.001(2)(f)2, Florida Administrative Code, promulgated by the Department of Insurance in June 2000 to govern the method and procedure the NICA medical advisory panel was to use in reviewing NICA claims, defined "substantial mental impairment" to be:
For a mental neurological impairment to be substantial, the infant must exhibit a severe mental impairment such that the infant has or would score, within a reasonable degree of medical probability, 50 or below on the mental component of the Bayley Scales of Infant Development (between 12-14 months) or the Stanford Binet Intelligence Test (between ages 4-5).
(emphasis added). Fla. Stat. § 766.308, which established and provided for the medical advisory panel, was part of the NICA statute until its repeal in July 2001.