Title: North Broward Hospital District v. Kalitan
Citation: N/A
Docket Number: SC15-1858
State: Florida
Issuer: Florida Supreme Court
Date: June 8, 2017

Supreme Court of Florida 
 
 
____________ 
 
No. SC15-1858 
____________ 
 
NORTH BROWARD HOSPITAL DISTRICT, etc., et al., 
Appellants, 
 
vs. 
 
SUSAN KALITAN, 
Appellee. 
 
[June 8, 2017] 
 
PER CURIAM. 
This case is before the Court on appeal from a decision of the Fourth District 
Court of Appeal, North Broward Hospital District v. Kalitan, 174 So. 3d 403 (Fla. 
4th DCA 2015), which held section 766.118, Florida Statutes (2011), to be invalid.  
We have jurisdiction.  See art. V, § 3(b)(1), Fla. Const.  For the following reasons, 
we affirm the Fourth District’s decision and hold that the caps on personal injury 
noneconomic damages in medical negligence actions provided in section 766.118 
violate the Equal Protection Clause of the Florida Constitution.1 
                                          
 
 
1.  Because our conclusion regarding the invalidity of section 766.118 is 
dispositive, we find it unnecessary to address the remaining constitutional 
 
 
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FACTS AND PROCEDURAL HISTORY 
This case arose after complications from carpal tunnel surgery left appellee 
Susan Kalitan severely injured.  After trial, Kalitan’s noneconomic damages were 
capped by sections 766.118(2) and (3).  Section 766.118(2) provides that in a cause 
of action for personal injury arising from the medical negligence of practitioners, 
the noneconomic damages award shall not exceed $500,000 per claimant; 
however, if the negligence resulted in a permanent vegetative state or death, or if 
the negligence caused a catastrophic injury and a manifest injustice would occur 
unless increased damages are awarded, then damages may be awarded in an 
amount up to $1 million.  Section 766.118(3) similarly limits damages to $750,000 
and $1.5 million, respectively, when the injury results from the negligence of 
nonpractitioners.  The Fourth District held that the statutory caps on noneconomic 
damage awards in personal injury medical malpractice actions are unconstitutional, 
relying on this Court’s decision in Estate of McCall v. United States, 134 So. 3d 
894 (Fla. 2014), which held that the cap on wrongful death noneconomic damages 
provided in section 766.118 violates the Equal Protection Clause of the Florida 
Constitution.  Art. I, § 2, Fla. Const. 
                                          
 
challenges.  Additionally, we decline to reach the issues raised by the parties that 
do not fall under this Court’s mandatory jurisdiction. 
 
 
- 3 - 
The Fourth District presented the following facts of Kalitan’s injury and the 
ensuing medical malpractice lawsuit: 
 
I.  Background 
In 2007, Plaintiff went to defendant North Broward Hospital 
District (“the Hospital”) for outpatient surgery to treat carpal tunnel 
syndrome in her wrist.  The surgery required Plaintiff to be placed 
under general anesthesia. . . . 
During intubation, as part of the administration of anesthesia 
for Plaintiff’s surgery, one of the tubes perforated Plaintiff’s 
esophagus.  Prior to the surgery and intubation, Plaintiff had no 
problems with her esophagus, nor did she complain of any bodily pain 
unassociated with her carpal tunnel. . . . 
When Plaintiff awoke in recovery, she complained of 
excruciating pain in her chest and back.  The Anesthesiologist was 
notified, and, unaware of the perforated esophagus, he ordered the 
administration of a drug for the chest pain and concluded that there 
was no issue with Plaintiff’s heart.  Plaintiff was discharged from the 
hospital later that afternoon.  Plaintiff’s neighbor picked her up and 
drove her home. 
The neighbor returned the next day to check on Plaintiff.  
Plaintiff was unresponsive, so the neighbor took her to the emergency 
room of a nearby hospital.  Upon diagnosis of the problem, Plaintiff 
was rushed into lifesaving surgery to repair her esophagus.  Plaintiff’s 
next memory was waking up in the intensive care unit after being in a 
drug-induced coma for several weeks.  Plaintiff had additional 
surgeries and underwent intensive therapy to begin eating again and 
regain mobility.  She testified that she continues to suffer from pain 
throughout the upper half of her body and from serious mental 
disorders as a result of the traumatic incident and the loss of 
independence because of her body’s physical limitations following 
this incident. 
II.  Plaintiff’s Medical Malpractice Lawsuit 
Plaintiff filed a medical negligence action against Defendants.  
The issues at trial encompassed personal liability and vicarious 
liability for Plaintiff’s injuries, as well as the extent of the injuries and 
whether they amounted to “catastrophic injury” under section 
 
 
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766.118(1)(a).  At the end of Plaintiff’s case, all parties moved for 
directed verdict on various grounds.  Primarily, Defendants contended 
that Plaintiff failed to meet the threshold for a determination of 
catastrophic injury. . . . 
Ultimately, the trial court decided to submit [] two highly 
contested issues to the jury as questions on the verdict form. . . .  With 
regard to catastrophic injury, the jury was asked to determine whether 
Plaintiff suffered a “permanent impairment constituted by either . . . 
[s]pinal cord injury involving severe paralysis of an arm, a leg, or the 
trunk . . . [or] [s]evere brain or closed-head injury evidenced by a 
severe episodic neurological disorder.” 
 . . . [T]he jury determined that Plaintiff suffered catastrophic 
injury in the form of a “[s]evere brain or closed-head injury evidenced 
by a severe episodic neurological disorder” and awarded Plaintiff 
$4,718,011 in total damages.  The noneconomic damage awards were 
$2 million for past pain and suffering and $2 million for future pain 
and suffering. 
Multiple post-trial motions were filed, with Defendants 
primarily challenging the jury’s finding of catastrophic injury by way 
of severe brain or closed-head injury.  Defendants argued that there 
was no evidence in the record to support the jury’s finding of such an 
injury. . . .  All motions challenging the finding of catastrophic injury 
[] were denied.  The court also rejected Plaintiff’s challenge that the 
section 766.118 caps on noneconomic damages in medical negligence 
actions were unconstitutional. 
The trial court issued a written final judgment as to 
damages. . . .  The court [] limited the noneconomic damage awards 
by the caps provided in section 766.118, Florida Statutes (2011), after 
applying the increased cap for the finding of catastrophic injury, 
because the court found that competent substantial evidence existed in 
the record to support a finding of catastrophic injury under the 
statutory definition as determined by the jury.  As such, the 
noneconomic damages award of $4 million was reduced by close to 
$2 million by the “[l]imitation on noneconomic damages for 
negligence of practitioners” under section 766.118(2) and 
“[l]imitation on noneconomic damages for negligence of 
nonpractitioner defendants” under section 766.118(3), Florida Statutes 
(2011).  Furthermore, the noneconomic damages award was further 
 
 
- 5 - 
reduced by about $1.3 million, as the Hospital’s share of liability was 
capped at $100,000 by virtue of the hospital’s status as a sovereign 
entity.  § 768.28, Fla. Stat. (2007). 
 
Kalitan, 174 So. 3d at 405-07. 
 
In its analysis with regard to Kalitan’s constitutional challenge to the caps, 
the Fourth District observed that a majority of this Court in McCall determined that 
the cap on wrongful death noneconomic damages under section 766.118 violates 
the right to equal protection guaranteed by article I, section 2, of the Florida 
Constitution.  The district court described the facts of McCall and highlighted 
relevant portions of the plurality and concurring in result opinions regarding the 
arbitrariness of the cap and the lack of a legitimate government interest justifying 
the cap.  Although the Fourth District recognized that the decision in McCall was 
limited to a determination that the cap on noneconomic damages is 
unconstitutional in the context of wrongful death actions, it observed that section 
766.118 applies to both wrongful death and personal injury actions.  Thus, the 
district court applied this Court’s rationale in McCall to the personal injury 
context, concluding that “McCall mandates a finding that the caps in section 
766.118 personal injury cases are similarly unconstitutional.”  Id. at 405. 
 
 
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Therefore, the Fourth District directed the trial court to reinstate the total damages 
award as found by the jury.  This appeal followed.2 
STATUTORY PROVISION 
 
The issue before this Court concerns the caps on personal injury 
noneconomic damages in medical negligence actions provided in section 766.118, 
which states: 
 
(2)  LIMITATION ON NONECONOMIC DAMAGES FOR 
NEGLIGENCE OF PRACTITIONERS.— 
 
(a)  With respect to a cause of action for personal injury or 
wrongful death arising from medical negligence of practitioners, 
regardless of the number of such practitioner defendants, 
noneconomic damages shall not exceed $500,000 per claimant.  No 
practitioner shall be liable for more than $500,000 in noneconomic 
damages, regardless of the number of claimants. 
 
(b)  Notwithstanding paragraph (a), if the negligence resulted in 
a permanent vegetative state or death, the total noneconomic damages 
recoverable from all practitioners, regardless of the number of 
claimants, under this paragraph shall not exceed $1 million.  In cases 
that do not involve death or permanent vegetative state, the patient 
injured by medical negligence may recover noneconomic damages not 
to exceed $1 million if: 
 
1.  The trial court determines that a manifest injustice would 
occur unless increased noneconomic damages are awarded, based on a 
finding that because of the special circumstances of the case, the 
noneconomic harm sustained by the injured patient was particularly 
severe; and 
                                          
 
 
2.  While this case was pending, the Second District Court of Appeal issued 
Port Charlotte HMA, LLC v. Suarez, 210 So. 3d 187 (Fla. 2d DCA 2016), in which 
it agreed with the Fourth District’s conclusion that the statutory caps on personal 
injury noneconomic damages are unconstitutional. 
 
 
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2.  The trier of fact determines that the defendant’s negligence 
caused a catastrophic injury to the patient. 
 
(c)  The total noneconomic damages recoverable by all 
claimants from all practitioner defendants under this subsection shall 
not exceed $1 million in the aggregate. 
 
(3)  LIMITATION ON NONECONOMIC DAMAGES FOR 
NEGLIGENCE OF NONPRACTITIONER DEFENDANTS.— 
 
(a)  With respect to a cause of action for personal injury or 
wrongful death arising from medical negligence of nonpractitioners, 
regardless of the number of such nonpractitioner defendants, 
noneconomic damages shall not exceed $750,000 per claimant. 
 
(b)  Notwithstanding paragraph (a), if the negligence resulted in 
a permanent vegetative state or death, the total noneconomic damages 
recoverable by such claimant from all nonpractitioner defendants 
under this paragraph shall not exceed $1.5 million.  The patient 
injured by medical negligence of a nonpractitioner defendant may 
recover noneconomic damages not to exceed $1.5 million if: 
 
1.  The trial court determines that a manifest injustice would 
occur unless increased noneconomic damages are awarded, based on a 
finding that because of the special circumstances of the case, the 
noneconomic harm sustained by the injured patient was particularly 
severe; and 
 
2.  The trier of fact determines that the defendant’s negligence 
caused a catastrophic injury to the patient. 
 
(c)  Nonpractitioner defendants are subject to the cap on 
noneconomic damages provided in this subsection regardless of the 
theory of liability, including vicarious liability. 
 
(d)  The total noneconomic damages recoverable by all 
claimants from all nonpractitioner defendants under this subsection 
shall not exceed $1.5 million in the aggregate. 
 
§§ 766.118(2), (3), Fla. Stat. 
 
 
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ESTATE OF MCCALL V. UNITED STATES 
To determine the constitutionality of this statute, we first examine McCall, 
in which we held that the cap on wrongful death noneconomic damages provided 
in section 766.118 is unconstitutional.  134 So. 3d at 897.  The case involved an 
action brought by the Estate of Michelle McCall, who died as a result of medical 
negligence following the birth of her son.  In McCall, we addressed certified 
questions from the United States Court of Appeals for the Eleventh Circuit and 
considered whether the cap on wrongful death noneconomic damages violates the 
right to equal protection.  The plurality opinion concluded that section 766.118 
violates the Equal Protection Clause because the statutory cap “imposes unfair and 
illogical burdens on injured parties” and “does not bear a rational relationship to 
the stated purpose that the cap is purported to address, the alleged medical 
malpractice insurance crisis in Florida.”  Id. at 901. 
 
In analyzing the arbitrary distinctions created by the statute, the plurality 
opinion concluded that the cap “irrationally impacts circumstances which have 
multiple claimants/survivors differently and far less favorably than circumstances 
in which there is a single claimant/survivor . . .” and that “under section 766.118, 
the greater the number of survivors and the more devastating their losses are, the 
less likely they are to be fully compensated for those losses.”  Id. at 901-02. 
 
 
- 9 - 
Additionally, the plurality opinion described how the cap on noneconomic 
damages arbitrarily discriminates between slightly and severely injured plaintiffs 
while benefitting the tortfeasor.  The opinion presented the following hypothetical 
from the Supreme Court of Illinois: 
In the first example . . . three plaintiffs are injured as a result of 
the same tortfeasor’s negligence.  Plaintiff A is injured moderately, 
and suffers pain, disability and disfigurement for a month.  Plaintiff B 
is severely injured and suffers one year of pain and disability.  
Plaintiff C is drastically injured, and suffers permanent pain and 
disability. . . .  [I]t is further assumed that a jury awards plaintiffs A 
and B $100,000 in compensatory damages for noneconomic injuries.  
Plaintiff C receives $1 million for his permanent, lifelong pain and 
disability. 
. . . With respect to plaintiff C, [the challenged legislation] 
arbitrarily and automatically reduces the jury’s award for a lifetime of 
pain and disability, without regard to whether or not the verdict, 
before reduction, was reasonable and fair. 
The tortfeasors in this example are also treated differently, 
without any justification.  The tortfeasor who injures plaintiffs A and 
B is liable for the full amount of fairly assessed compensatory 
damages.  In contrast, [the challenged legislation] confers a benefit on 
the similarly situated tortfeasor who injures plaintiff C.  This 
tortfeasor pays only a portion of fairly assessed compensatory 
damages because of the limitation [on noneconomic damages].  
Therefore, the statute discriminates between slightly and severely 
injured plaintiffs, and also between tortfeasors who cause severe and 
moderate or minor injuries. 
 
Id. at 902-03 (quoting Best v. Taylor Mach. Works, 689 N.E.2d 1057, 1075 (Ill. 
1997)). 
Based on this analysis, the plurality opinion stated: 
 
 
- 10 - 
Section 766.118, Florida Statutes, has the effect of saving a 
modest amount for many by imposing devastating costs on a few—
those who are the most grievously injured, those who sustain the 
greatest damage and loss, and multiple claimants for whom judicially 
determined noneconomic damages are subject to division and 
reduction simply based upon the existence of the cap.  Under the 
Equal Protection Clause of the Florida Constitution, and guided by 
our decision in [St. Mary’s Hospital, Inc. v. Phillipe, 769 So. 2d 961 
(Fla. 2000)], we hold that to reduce damages in this fashion is not 
only arbitrary, but irrational, and we conclude that it “offends the 
fundamental notion of equal justice under the law.” 
 
Id. at 903 (quoting Phillipe, 769 So. 2d at 972). 
The plurality opinion additionally concluded that the cap on noneconomic 
damages “bears no rational relationship to a legitimate state objective, thereby 
failing the rational basis test.”  Id. at 905.  The Florida Legislature’s purpose in 
enacting the statute was to address the medical malpractice insurance crisis.  See 
ch. 2003–416, § 1, Laws of Fla., at 4035.  “The Legislature asserted that the 
increase in medical malpractice liability insurance premiums has resulted in 
physicians leaving Florida, retiring early from the practice of medicine, or refusing 
to perform high-risk procedures, thereby limiting the availability of health care.”  
McCall, 134 So. 3d at 906.  However, the plurality opinion determined that the 
findings by the Legislature as to the existence of a medical malpractice crisis were 
not fully supported by available data. 
 
The plurality opinion then declared that even if the Legislature’s findings 
were true, “section 766.118 still violates Florida’s Equal Protection Clause because 
 
 
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the available evidence fails to establish a rational relationship between a cap on 
noneconomic damages and alleviation of the purported crisis.”  Id. at 909.  The 
opinion observed a lack of evidence establishing a direct correlation between caps 
and reduced malpractice premiums.  Thus, it adopted the reasoning of the Texas 
Supreme Court, which addressed whether caps on damages would lower insurance 
premiums, observing: “[i]n the context of persons catastrophically injured by 
medical negligence, we believe it is unreasonable and arbitrary to limit their 
recovery in a speculative experiment to determine whether liability insurance rates 
will decrease.”  Id. at 912 (quoting Lucas v. United States, 757 S.W.2d 687, 691 
(Tex. 1988)). 
 
Furthermore, the plurality opinion asserted that even if there existed a 
medical malpractice crisis when the statute was enacted, “[c]onditions can change, 
which remove or negate the justification for a law, transforming what may have 
once been reasonable into arbitrary and irrational legislation.”  Id. at 913.  After 
reviewing current data, the opinion declared that “no rational basis exists to justify 
continued application of the noneconomic damages cap of section 766.118.”  Id.  
Ultimately, the plurality opinion concluded that “the cap on noneconomic damages 
serves no purpose other than to arbitrarily punish the most grievously injured or 
their surviving family members.”  Id. at 914-15. 
 
 
- 12 - 
The concurring in result opinion agreed that “the arbitrary reduction of 
survivors’ noneconomic damages in wrongful death cases based on the number of 
survivors lacks a rational relationship to the goal of reducing medical malpractice 
premiums.”  Id. at 916 (Pariente, J., concurring in result).  The concurring in result 
opinion observed that “the only asserted legitimate State interest is the alleviation 
of rising medical malpractice insurance premiums paid by the affected doctors.”  
Id. at 919 (Pariente, J., concurring in result).  However, the opinion determined that 
“there is no mechanism in place to assure that savings are actually passed on from 
the insurance companies to the doctors.”  Id. (Pariente, J., concurring in result) 
(citing plurality op. at 911-12 (Lewis, J.)).  Moreover, the concurring in result 
opinion agreed that a legislative finding that there was a medical malpractice crisis 
does not establish a permanent condition because a statute may become 
constitutionally invalid due to changed conditions.  Id. at 920 (Pariente, J., 
concurring in result) (citing Mizrahi v. N. Miami Med. Ctr., Ltd., 761 So. 2d 1040, 
1043 (Fla. 2000) (Pariente, J., dissenting)).  Thus, it concluded that there was no 
evidence of a continuing medical malpractice crisis that would justify the arbitrary 
application of the statutory cap in wrongful death cases.  Id. at 921 (Pariente, J., 
concurring in result). 
We now consider the applicability of McCall to the personal injury context 
at issue in the present case. 
 
 
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EQUAL PROTECTION 
 “The determination of a statute’s constitutionality and the interpretation of a 
constitutional provision are both questions of law reviewed de novo.”  Shands 
Teaching Hosp. & Clinics, Inc. v. Mercury Ins. Co. of Fla., 97 So. 3d 204, 209 
(Fla. 2012) (quoting Fla. Dept. of Revenue v. City of Gainesville, 918 So. 2d 250, 
256 (Fla. 2005)). 
The Florida Constitution declares that “[a]ll natural persons, female and 
male alike, are equal before the law.”  Art. I, § 2, Fla. Const.  “The constitutional 
right of equal protection of the laws means that everyone is entitled to stand before 
the law on equal terms with, to enjoy the same rights as belong to, and to bear the 
same burden as are imposed upon others in a like situation.”  Caldwell v. Mann, 26 
So. 2d 788, 790 (1946).  “Unless a suspect class or fundamental right protected by 
the Florida Constitution is implicated by the challenged provision, the rational 
basis test will apply to evaluate an equal protection challenge.”  McCall, 134 So. 
3d at 901.  “To satisfy the rational basis test, a statute must bear a rational and 
reasonable relationship to a legitimate state objective, and it cannot be arbitrary or 
capriciously imposed.”  Id. (citing Dep’t of Corr. v. Fla. Nurses Ass’n, 508 So. 2d 
317, 319 (Fla. 1987)); see also Amerisure Ins. Co. v. State Farm Mut. Auto. Ins. 
Co., 897 So. 2d 1287, 1290 n.2 (Fla. 2005).  Where a challenger fails to meet this 
 
 
- 14 - 
burden, the statute must be upheld.  Fla. High Sch. Activities Ass’n, Inc. v. 
Thomas, 434 So. 2d 306, 308 (Fla. 1983). 
Here, we address whether sections 766.118(2) and 766.118(3) violate the 
right to equal protection guaranteed by the Florida Constitution.  Kalitan is not a 
member of a suspect class; thus the rational basis test applies.  Appellants argue 
that the statutory caps in single claimant personal injury actions are constitutional 
and that the Fourth District erred in determining that the reasoning in McCall 
controls.  However, we disagree and hold that the caps in section 766.118 violate 
equal protection under the rational basis test because the arbitrary reduction of 
compensation without regard to the severity of the injury does not bear a rational 
relationship to the Legislature’s stated interest in addressing the medical 
malpractice crisis. 
Arbitrariness of Classification 
In McCall, we concluded that the cap on wrongful death noneconomic 
damages imposed by section 766.118 arbitrarily diminished noneconomic damage 
awards based on the number of survivors and lacked a rational relationship to 
addressing the medical malpractice crisis.  The Fourth District below determined 
that the reasoning in McCall mandated a holding that the statutory caps in section 
766.118 were similarly unconstitutional in personal injury actions because the 
reasoning of the plurality and concurring in result opinions struck at the 
 
 
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“underpinning of the Legislature’s cap on noneconomic damages in general.”  
Kalitan, 174 So. 3d at 413.  Based on the agreement between the plurality and 
concurring in result opinions in McCall that there is no evidence of a continuing 
medical malpractice crisis justifying the arbitrary application of the statutory cap, 
we reach the same conclusion with regard to the unconstitutionality of the caps in 
the present case. 
After the plurality opinion in McCall presented the hypothetical describing 
discrimination between slightly and severely injured plaintiffs under a statutory 
provision, it observed that section 766.118 has the effect of saving a modest 
amount for many by imposing devastating costs on the most grievously injured, 
and those who sustain the greatest damage and loss.  McCall, 134 So. 3d at 903.  
The plurality opinion concluded that reducing damages for the most grievously 
injured is “not only arbitrary, but irrational, and . . . that it ‘offends the 
fundamental notion of equal justice under the law.’ ”  Id. (quoting Phillipe, 769 So. 
2d at 972). 
Like the hypothetical statutory provision discussed in McCall, sections 
766.118(2) and (3) create a similar distinction between classes of medical 
malpractice victims, arbitrarily reducing the damages that may be awarded to the 
most drastically injured victims.  Section 766.118(2) provides a cap of $500,000 in 
noneconomic damages to a plaintiff who suffers from a practitioner’s negligence 
 
 
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and increases the cap to $1 million in the event of death, permanent vegetative 
state, or “catastrophic injury” where a manifest injustice would occur unless 
increased damages are awarded.  Similarly, section 766.118(3) provides a cap of 
$750,000 in noneconomic damages to a plaintiff who suffers from a 
nonpractitioner’s negligence and increases the cap to $1.5 million in the event of 
death, permanent vegetative state, or “catastrophic injury” where a manifest 
injustice would occur unless increased damages are awarded. 
Notably, within the definition of “catastrophic injury,”3 in section 
766.118(1)(a), the Legislature defined instances that range from amputation of a 
                                          
 
 
3.  Section 766.118(1)(a) defines “catastrophic injury” as:  
[A] permanent impairment constituted by: 
1.  Spinal cord injury involving severe paralysis of an arm, a leg, or 
the trunk; 
2.  Amputation of an arm, a hand, a foot, or a leg involving the 
effective loss of use of that appendage; 
3.  Severe brain or closed-head injury as evidenced by: 
a.  Severe sensory or motor disturbances; 
b.  Severe communication disturbances; 
c.  Severe complex integrated disturbances of cerebral function; 
d.  Severe episodic neurological disorders; or 
e.  Other severe brain and closed-head injury conditions at least as 
severe in nature as any condition provided in sub-subparagraphs a.-d.; 
4.  Second-degree or third-degree burns of 25 percent or more of the 
total body surface or third-degree burns of 5 percent or more to the 
face and hands; 
5.  Blindness, defined as a complete and total loss of vision; or 
 
 
- 17 - 
hand to severe brain or closed-head injury.  Thus, sections 766.118(2) and (3) 
impose equal caps on noneconomic damages in instances where a plaintiff suffers 
a permanent vegetative state, unquestionably a more serious injury, as in instances 
where a plaintiff suffers the amputation of a hand, if a court determines a manifest 
injustice would occur unless increased damages are awarded.  Consequently, 
sections 766.118(2) and (3) set forth the same problematic scheme that the 
plurality opinion in McCall agreed created arbitrary and invidious discrimination 
between claimants. 
To illustrate this example, we examine the hypothetical recovery of 
noneconomic damages for plaintiffs A, B, and C under sections 766.118(2) and 
(3).  Plaintiff A suffers a moderate injury; therefore recovery is capped at $500,000 
if caused by a practitioner and $750,000 if caused by a nonpractitioner.  Plaintiff B 
suffers a statutorily defined “catastrophic injury,” such as the loss of a hand; 
therefore recovery may be capped at $1 million if caused by a practitioner and $1.5 
million if caused by a nonpractitioner.  Plaintiff C suffers a drastic injury, such as a 
permanent vegetative state; therefore recovery is capped at $1 million if caused by 
                                          
 
6.  Loss of reproductive organs which results in an inability to 
procreate. 
 
§ 766.118(1)(a), Fla. Stat. 
 
 
 
- 18 - 
a practitioner and $1.5 million if caused by a nonpractitioner.  Under these 
circumstances, plaintiff A has the best chance of being fully compensated, plaintiff 
B may have a chance of being fully compensated, and plaintiff C has utterly no 
chance of being fully compensated.  Clearly, under sections 766.118(2) and (3), 
plaintiff C’s damages award is arbitrarily diminished, even though plaintiff C has 
suffered the most grievous injury. 
The caps under section 766.118 do not pass the rational basis test because 
“[i]n the context of persons catastrophically injured by medical negligence, we 
believe it is unreasonable and arbitrary to limit their recovery in a speculative 
experiment to determine whether liability insurance rates will decrease.”  McCall, 
134 So. 3d at 912 (quoting Lucas, 757 S.W.2d at 691).  Moreover, we “fail to see 
how singling out the most seriously injured medical malpractice victims for less 
than full recovery bears any rational relationship to the Legislature’s stated goal of 
alleviating the financial crisis in the medical liability insurance industry.”  Univ. of 
Miami v. Echarte, 618 So. 2d 189, 198 (Fla. 1993) (Barkett, C.J., dissenting).4  
Therefore, we agree with the Fourth District’s conclusion: 
                                          
 
 
4.  While in Echarte this Court upheld the constitutionality of a noneconomic 
damages cap in medical malpractice arbitration proceedings, the dissenting 
opinion’s discussion of the equal protection issue regarding the statute’s creation of 
two classifications of medical malpractice victims proves insightful under the facts 
at issue. 
 
 
- 19 - 
So long as the caps discriminate between classes of medical 
malpractice victims, as they do in the personal injury context (where 
the claimants with little noneconomic damage can be awarded all of 
their damages, in contrast to those claimants whose noneconomic 
damages are deemed to exceed the level to which the caps apply), 
they are rendered unconstitutional by McCall. 
 
Kalitan, 174 So. 3d at 413. 
Accordingly, we conclude that the statutory caps in section 766.118 
unreasonably and arbitrarily limit recovery of those most grievously injured by 
medical negligence. 
Rational Relationship to Legitimate State Objective 
Although we conclude the arbitrary caps are not rationally related to 
alleviating the purported medical malpractice crisis, we nonetheless consider the 
legitimacy of the asserted state objective.  In enacting section 766.118, the Florida 
Legislature found that “Florida [was] in the midst of a medical malpractice 
insurance crisis of unprecedented magnitude.”  Ch. 2003-416, § 1, Laws of Fla., at 
4035.  However, in McCall, we observed a lack of evidence demonstrating how the 
statutory cap alleviated this crisis, and thus determined that the cap failed the 
rational basis test.  The plurality opinion cited evidence that showed an increase in 
income for insurance companies, yet declared that “[r]eports have failed to 
establish a direct correlation between damage caps and reduced medical 
malpractice premiums” that were intended to reduce instances of doctors leaving 
Florida, retiring early, or refusing to perform high risk procedures.  McCall, 134 
 
 
- 20 - 
So. 3d at 910.  The concurring in result opinion reiterated the plurality’s 
observation that there is no mechanism in place to assure that savings are passed 
on from the insurance companies to the doctors in accordance with the stated 
purpose of alleviating the rising premiums.  Id. at 919 (Pariente, J., concurring in 
result). 
Furthermore, in McCall, we determined that even if the damages cap were 
rationally related to a legitimate government purpose when the statute was enacted, 
there is no evidence of a continuing crisis that would justify the arbitrary 
application of the statutory cap.  Both the plurality and concurring in result 
opinions recognized that “[a] statute may be constitutionally valid when enacted 
but may become constitutionally invalid because of changes in the conditions to 
which the statute applies.”  Id. at 913 (quoting Ferdon ex rel. Petrucelli v. 
Wisconsin Patients Comp. Fund, 701 N.W.2d 440, 468 (Wis. 2005)); see also id. at 
920 (Pariente, J., concurring in result) (quoting Mizrahi, 761 So. 2d at 1043 
(Pariente, J., dissenting)).  Moreover, the plurality opinion observed that “[a] law 
depending upon the existence of an emergency or other certain state of facts to 
uphold it may cease to operate if the emergency ceases or the facts change even 
though valid when passed.”  McCall, 134 So. 3d at 913 (quoting Chastleton Corp. 
v. Sinclair, 264 U.S. 543, 547-48, (1924)).  The plurality opinion explained: “even 
if there had been a medical malpractice crisis in Florida at the turn of the century, 
 
 
- 21 - 
the current data reflects that it has subsided.  No rational basis currently exists (if it 
ever existed) between the cap imposed by section 766.118 and any legitimate state 
purpose.”  Id. at 914.  The concurring in result opinion agreed that there is no 
evidence of a continuing medical malpractice crisis that would justify the arbitrary 
reduction of damages.  Id. at 921 (Pariente, J., concurring in result).  Consequently, 
we approve the Fourth District’s conclusion: “Because addressing the medical 
malpractice crisis was the Legislature’s stated objective when passing section 
766.118, if the objective no longer exists, then there is no longer a ‘legitimate state 
objective’ to which the caps could ‘rationally and reasonably relate.’ ”  Kalitan, 
174 So. 3d at 411. 
We note that Kalitan’s reliance on McCall to establish that the statutory caps 
failed the rational basis test satisfied her burden of proving that the statute is not 
rationally related to a legitimate government interest.  Accordingly, we hold that 
the arbitrary caps on personal injury noneconomic damages in sections 766.118(2) 
and (3) bear no rational relationship to a legitimate government interest. 
CONCLUSION 
 
We conclude that the caps on noneconomic damages in sections 766.118(2) 
and (3) arbitrarily reduce damage awards for plaintiffs who suffer the most drastic 
injuries.  We further conclude that because there is no evidence of a continuing 
medical malpractice insurance crisis justifying the arbitrary and invidious 
 
 
- 22 - 
discrimination between medical malpractice victims, there is no rational 
relationship between the personal injury noneconomic damage caps in section 
766.118 and alleviating this purported crisis.  Therefore, we hold that the caps on 
personal injury noneconomic damages provided in section 766.118 violate the 
Equal Protection Clause of the Florida Constitution. 
Accordingly, we affirm the Fourth District’s decision, and remand to the 
district court for further proceedings consistent with this opinion. 
 
It is so ordered. 
 
LABARGA, C.J., and PARIENTE, LEWIS, and QUINCE, JJ., concur. 
POLSTON, J., dissents with an opinion, in which CANADY and LAWSON, JJ., 
concur. 
 
NOT FINAL UNTIL TIME EXPIRES TO FILE REHEARING MOTION, AND 
IF FILED, DETERMINED. 
 
POLSTON, J., dissenting. 
 
Just as I dissented to the erroneous plurality and concurring in result 
decisions in Estate of McCall v. United States, 134 So. 3d 894 (Fla. 2014), I 
dissent to the majority’s decision in this case.  The majority continues to disregard 
our precedent’s rational basis standard as well as the Legislature’s policymaking 
role in our constitutional system.  Under a proper rational basis analysis, the cap on 
noneconomic damages in section 766.118, Florida Statutes, easily passes 
constitutional muster.     
 
 
- 23 - 
 
The Florida Constitution guarantees that “[a]ll natural persons, female and 
male alike, are equal before the law.”  Art. I, § 2, Fla. Const.  Our precedent has 
interpreted this provision consistently with interpretations of the equal protection 
clause in the federal constitution.  See, e.g., Duncan v. Moore, 754 So. 2d 708, 712 
(Fla. 2000).  And because the classification alleged in this case does not involve a 
protected class or a fundamental right, this Court must employ the rational basis 
test.  Id.    
 
“Under a ‘rational basis’ standard of review a court should inquire only 
whether it is conceivable that the regulatory classification bears some rational 
relationship to a legitimate state purpose.”  Fla. High Sch. Activities Ass’n v. 
Thomas, 434 So. 2d 306, 308 (Fla. 1983).  “The burden is upon the party 
challenging the statute or regulation to show that there is no conceivable factual 
predicate which would rationally support the classification under attack.”  Id.  
Furthermore, under the rational basis test, “[i]t is not the court’s function to 
determine whether the legislation achieves its intended goal in the best manner 
possible, but only whether the goal is legitimate and the means to achieve it are 
rationally related to the goal.”  Loxahatchee River Envtl. Control Dist. v. Sch. Bd. 
of Palm Beach Cty., 496 So. 2d 930, 938 (Fla. 4th DCA 1986). 
 
Here, when enacting the noneconomic damages cap in section 766.118, the 
Legislature found that Florida’s medical malpractice crisis “threatens the quality 
 
 
- 24 - 
and availability of health care for all Florida citizens,” that the “cost of medical 
malpractice insurance has increased dramatically during the past decade,” and that 
“both the increase and the current cost are substantially higher than the national 
average.”  Ch. 2003-416, at § 1, Laws of Fla.  The Florida Legislature concluded 
that physicians are forced “to practice medicine without professional liability 
insurance, to leave Florida, to not perform high-risk procedures, or to retire early 
from the practice of medicine.”  Id.  The Florida Legislature also found that “there 
are certain elements of damage presently recoverable that have no monetary value, 
except on a purely arbitrary basis, while other elements of damage are either easily 
measured on a monetary basis or reflect ultimate monetary loss” and that “the high 
cost of medical malpractice claims can be substantially alleviated by imposing a 
limitation on noneconomic damages in medical malpractice actions.”  Id. 
 
No one disputes that increasing the availability, quality, and affordability of 
healthcare in Florida constitutes a legitimate state interest.  This Court also has 
acknowledged that a medical malpractice insurance crisis constitutes a legitimate 
state interest under the rational basis test.  See Mizrahi v. N. Miami Med. Ctr., 
Ltd., 761 So. 2d 1040, 1042 n.3 (Fla. 2000); Univ. of Miami v. Echarte, 618 So. 2d 
189, 196-97 (Fla. 1993).  Furthermore, the Legislature’s policy choice of a cap on 
noneconomic damages is rationally related to these legitimate state interests 
because “limiting claims that may be advanced by some claimants would 
 
 
- 25 - 
proportionally limit claims made overall and would directly affect the cost of 
providing health care by making it less expensive and more accessible.”  Mizrahi, 
761 So. 2d at 1043.  Therefore, applying the proper rational basis test, it is clear 
that the statutory cap does not violate Florida’s guarantee of equal protection. 
 
Importantly, under the proper rational basis test, it is immaterial that the 
majority of this Court disagrees with the Legislature’s evidence regarding whether 
there was (or currently is) a medical malpractice crisis in Florida.  It is also 
immaterial that a majority of this Court questions whether the Legislature’s policy 
choice of enacting a cap on noneconomic damages has resulted in insurance 
companies passing along savings to their physician customers.   
Instead, under the rational basis test, “[t]he burden is upon the party 
challenging the statute . . . to show that there is no conceivable factual predicate 
which would rationally support the classification under attack.”  Fla. High Sch. 
Activities Ass’n, 434 So. 2d at 308.  In fact, “a legislative choice is not subject to 
courtroom fact-finding and may be based on rational speculation unsupported by 
evidence or empirical data.”  F.C.C. v. Beach Commc’ns, Inc., 508 U.S. 307, 315 
(1993).  “A State, moreover, has no obligation to produce evidence to sustain the 
rationality of a statutory classification.”  Heller v. Doe, 509 U.S. 312, 320 (1993).  
Thus, under the dictates of the rational basis test, if we can conceive of a possible 
factual predicate that provides a rational basis in furtherance of a legitimate state 
 
 
- 26 - 
interest, the statute does not violate the constitutional guarantee of equal 
protection.   
Applying the proper rational basis standard, as I explained in my dissent in 
McCall,  
the Florida Legislature could have rationally believed that the cap on 
noneconomic damages under section 766.118(2)(b) would reduce 
malpractice damage awards, which would thereby increase 
predictability in the medical malpractice insurance market and lead to 
reduced insurance premiums.  Then, as a result of decreased insurance 
premiums, physicians would be more willing to stay in Florida and 
perform high-risk procedures at a lower cost to Floridians.   
 
134 So. 3d at 930 (Polston, J., dissenting) (footnote omitted); see also M.D. v. 
United States, 745 F. Supp. 2d 1274, 1281 (M.D. Fla. 2010) (“A cap applicable to 
each occurrence, in cooperation with caps individually applicable to each claimant, 
reduces damage awards as a matter of mathematical certainty, enhances needed 
predictability, places a calculable limit on the exposure of healthcare and insurance 
providers, reduces malpractice insurance premiums, and promotes the availability 
of quality healthcare.”).  Additionally, “the Legislature simply may have felt that it 
was fairer to malpractice plaintiffs in general to reduce only the very large 
noneconomic damage awards, rather than to diminish the more modest recoveries 
for pain and suffering and the like in the great bulk of cases.”  Fein v. Permanente 
Med. Grp., 695 P.2d 665, 683 (Cal. 1985); see also Smith v. Botsford Gen. Hosp., 
419 F.3d 513, 520 (6th Cir. 2005) (“By limiting at least one component of health 
 
 
- 27 - 
care costs, the noneconomic damages limitation is rationally related to its intended 
purpose.” (quoting Zdrojewski v. Murphy, 657 N.W.2d 721, 739 (Mich. Ct. App. 
2002))); Boyd v. Bulala, 877 F.2d 1191, 1197 (4th Cir. 1989) (holding that 
statutory cap on all damages, including noneconomic damages, does not violate 
equal protection because it “bears a reasonable relation to a valid legislative 
purpose—the maintenance of adequate health care services in the Commonwealth 
of Virginia”); Davis v. Omitowoju, 883 F.2d 1155, 1158 (3d Cir. 1989) 
(“Clearly[,] the Virgin Island’s decision to curb, through legislation, the high costs 
of malpractice insurance and thereby promote quality medical care to the residents 
of the islands, provides a rational basis for capping the amount of damages that can 
be awarded a plaintiff.”); Lucas v. United States, 807 F.2d 414, 422 (5th Cir. 1986) 
(“Lucas has failed to convince us that there is no reasonable basis for the Texas 
legislature to conclude that this ceiling on recovery . . . is not conceivably related 
to the availability and cost of malpractice insurance and that such insurance and the 
distribution of medical care in Texas are not conceivably linked.”); Hoffman v. 
United States, 767 F.2d 1431, 1437 (9th Cir. 1985) (“It was reasonable for the 
lawmakers to believe that placing a ceiling on noneconomic damages would help 
reduce malpractice insurance premiums.”).   
Accordingly, the cap on noneconomic damages in medical malpractice 
actions is rationally related to the legitimate state interest of increasing the 
 
 
- 28 - 
affordability, availability, and quality of medical care in Florida.  Therefore, under 
the proper rational basis test that our long-standing precedent requires, the cap in 
section 766.118 passes constitutional muster.  
 
Moreover, as I explained in my dissent in McCall, the statutory “limitations 
on noneconomic damages are part of an overall legislative plan enacted in 2003 to 
address the rising costs of medical liability insurance and the affordability and 
availability of healthcare in Florida[:]” 
Other components of the plan include new healthcare facilities 
regulations, insurance regulation, license requirements, and agency 
requirements.  [See ch. 2003-416, Laws of Fla.]   
The legislative effort began with the convening of the House 
Select Committee on Medical Liability Insurance, which “conducted 
an inquiry into the possible causes and potential solutions to the 
vexing problems associated with the availability of medical liability 
insurance in Florida.”  Fla. H. Select Comm. on Med. Liab. Ins., 
Select Comm. on Med. Liab. Ins. Rep., at 2 (March 2003) (available 
at Fla. Dept. of State, Fla. State Archives, Tallahassee, Fla.).  The 
Select Committee examined “how the reduced availability of 
affordable medical liability insurance affects the availability of 
medical services” and was “mindful of the need to maintain the right 
of access to redress when citizens are harmed during the delivery of 
medical services.”  Id. at 3.  The Select Committee held a series of 
meetings in Tallahassee, held four hearings outside the capital, and 
published an 82 page report (not including appendices).  Id.  It 
“received testimony from experts in each of the professional areas 
impacted” and reviewed records from efforts to address prior crises.  
Id. at 4.   
The Select Committee also reviewed the record of the 
Governor’s Select Task Force on Health Care Professional Liability 
Insurance, which produced a “345 page report as well as thirteen 
volumes of supportive materials.”  Id. at 9.  The Governor’s Task 
Force “undertook a comprehensive review of published studies and 
relevant literature” and held ten meetings at which it received 
 
 
- 29 - 
extensive testimony and information.  Gov.’s Select Task Force on 
Healthcare Prof. Liab. Ins., Gov.’s Task Force on Healthcare Prof. 
Liab. Ins. Rep., at 3, iv (2003). 
 
134 So. 3d at 924-25 (Polston, J., dissenting). 
The majority just discards and ignores all of the Legislature’s work and fact-
finding.  But, under our constitutional system, it is the Legislature, not this Court, 
that is entitled to make laws as a matter of policy based upon the facts it finds.  See 
art. II, § 3, Fla. Const.; art. III, § 1, Fla. Const.  It is the Legislature’s task to decide 
whether a medical malpractice crisis exists, whether a medical malpractice crisis 
has abated, and whether the Florida Statutes should be amended accordingly.  For a 
majority of this Court to decide that a crisis no longer exists, if it ever existed, so it 
can essentially change a statute and policy it dislikes, improperly interjects the 
judiciary into a legislative function. 
I respectfully dissent. 
CANADY and LAWSON, JJ., concur. 
 
An Appeal from the District Court of Appeal – Statutory or Constitutional 
Invalidity 
 
 
Fourth District - Case Nos. 4D11-4833, 4D11-4834, & 4D11-4806 
 
 
(Broward County) 
 
Mark Hicks and Dinah Stein of Hicks, Porter, Ebenfeld & Stein, P.A., Miami, 
Florida, 
 
 
 
- 30 - 
for Appellants North Broward Hospital District d/b/a Broward General 
Medical Center, Rob Alexander, M.D., Edward Punzalan, CRNA and 
ANESCO North Broward, LLC 
 
Thomas A. Valdez and Jeffrey R. Creasman of Quintairos, Prieto, Wood & Boyer, 
P.A., Tampa, Florida, 
 
 
for Appellants Barry University, Inc., and Eleidy Miedes, SRNA 
 
Crane A. Johnstone and Scott P. Schlesinger of Schlesinger Law Offices, P.A., 
Fort Lauderdale, Florida; and Philip M. Burlington and Nichole J. Segal of 
Burlington & Rockenbach, P.A., West Palm Beach, Florida, 
 
 
for Appellee 
 
Pamela Jo Bondi, Attorney General, and Osvaldo Vazquez, Deputy Solicitor 
General, Tallahassee, Florida, 
 
 
for Amicus Curiae State of Florida 
 
Mark K. Delegal and Tiffany A. Roddenberry of Holland & Knight LLP, 
Tallahassee, Florida; and William W. Large of Florida Justice Reform Institute, 
Tallahassee, Florida, 
 
for Amici Curiae Florida Justice Reform Institute and Florida Hospital 
Association, Inc. 
 
Tracy Raffles Gunn of Gunn Appellate Practice, P.A., Tampa, Florida, 
 
 
for Amicus Curiae Florida Justice Association