Title: Shemika A. Burks v. St. Joseph's Hospital
Citation: N/A
Docket Number: 1997AP000466
State: Wisconsin
Issuer: Wisconsin Supreme Court
Date: July 8, 1999

SUPREME COURT OF WISCONSIN 
 
 
Case No.: 
97-0466 
 
 
Complete Title 
of Case: 
 
 
Shemika A. Burks, and PrimeCare Health  
Plan, Inc.,  
 
Plaintiffs, 
 
v. 
St. Joseph's Hospital,  
 
Defendant-Appellant, 
Wisconsin Patients Compensation Fund,  
 
Defendant-Respondent-Petitioner.  
 
ON REVIEW OF A DECISION OF THE COURT OF APPEALS 
Reported at:  223 Wis. 2d 265, 588 N.W.2d 927 
 
 
 
(Ct. App. 1998-Unpublished) 
 
 
Opinion Filed: 
July 8, 1999 
Submitted on Briefs: 
 
Oral Argument: 
May 27, 1999 
 
 
Source of APPEAL 
 
COURT: 
Circuit 
 
COUNTY: 
Milwaukee 
 
JUDGE: 
Arlene D. Connors 
 
 
JUSTICES: 
 
Concurred: 
Abrahamson, C.J., concurs (opinion filed) 
 
Dissented: 
Bradley, J., dissents (opinion filed) 
 
Not Participating:  
 
 
ATTORNEYS: 
For the defendant-respondent-petitioner there 
were briefs by Paul J. Kelly, Linda V. Meagher and Schellinger & 
Doyle, S.C., Brookfield and oral argument by Linda V. Meagher. 
 
 
For the defendant-appellant there was a brief by 
Mary K. Wolverton & Peter F. Mullaney and Peterson, Johnson & 
Murray, S.C., Milwaukee and oral argument by peter F. Mullaney. 
 
  
 
1 
 
NOTICE 
This opinion is subject to further editing and 
modification.  The final version will appear in 
the bound volume of the official reports. 
 
 
No. 97-0466  
 
STATE OF WISCONSIN               :        
        
 
 
 
 
IN SUPREME COURT 
 
 
Shemika A. Burks, and PrimeCare Health  
Plan, Inc.,  
 
          Plaintiffs, 
 
     v. 
 
St. Joseph's Hospital,  
 
          Defendant-Appellant, 
 
Wisconsin Patients Compensation Fund,  
 
          Defendant-Respondent-Petitioner.  
FILED 
 
JUL 8, 1999 
 
Marilyn L. Graves 
Clerk of Supreme Court 
Madison, WI 
 
 
 
 
 
REVIEW of a decision of the Court of Appeals.  Affirmed. 
¶1 
DAVID T. PROSSER, J.   The Wisconsin Patients 
Compensation Fund (Fund) seeks review of an unpublished court of 
appeals decision1 reversing the circuit court's conclusion that 
the Fund does not provide coverage for violations of the federal 
Emergency Medical Treatment and Active Labor Act (EMTALA).2  The 
issue presented is whether the Fund is required to provide 
excess coverage for damages resulting from a hospital's refusal 
or failure to provide medical treatment to a severely premature 
infant, an alleged violation of EMTALA. 
                     
1 Burks v. St. Joseph's Hospital, No. 97-0446, unpublished 
slip op. (Wis. Ct. App. Oct. 27, 1998).  
2 42 U.S.C. § 1395dd.  
No. 97-0466  
 
2 
FACTS 
¶2 
On April 1, 1993, Shemika A. Burks (Burks) arrived at 
the emergency room of St. Joseph's Hospital in Milwaukee, 
complaining 
of 
cramps 
and 
contractions.3 
 
The 
time 
was 
approximately 6:40 a.m.  Burks was about 22 weeks pregnant and 
not expecting to deliver until August 10, 1993, almost 19 weeks 
later. 
¶3 
One hour after she arrived, Burks gave birth to a baby 
daughter, Comelethaa, who weighed only 200 grams (approximately 
7 oz.) and measured 11 inches long.  The baby died at 10:15 
a.m., two and a half hours after delivery. 
¶4 
In a subsequent lawsuit against the hospital, Burks 
alleged that her daughter was breathing and had a heartbeat at 
birth.  She claimed the hospital staff denied her requests for 
medical assistance to the infant after birth and that the baby 
died in her arms. 
¶5 
St. Joseph's Hospital contended that it would not have 
been appropriate to resuscitate such a severely premature baby. 
 In an affidavit filed later in the circuit court, Dr. Karlo 
Raab, a neonatologist at St. Joseph's Hospital, stated that "no 
attempt was made to resuscitate Shemika Burks' fetus" and that 
"resuscitation was not medically indicated for Shemika Burks' 
fetus and in fact is medically inappropriate for any fetus 
weighing 200 grams." 
                     
3 Burks was covered for any necessary treatment by her 
health insurer, PrimeCare Health Plan, Inc.  
No. 97-0466  
 
3 
PROCEDURAL HISTORY 
¶6 
On March 30, 1995, Burks and her health insurer, 
PrimeCare Health Plan, Inc., filed a complaint against St. 
Joseph's Hospital and the Wisconsin Patient Compensation Fund 
(Fund) in Milwaukee County Circuit Court.  The complaint alleged 
three causes of action.  First, Burks alleged that St. Joseph's 
Hospital, 
acting 
through 
its 
agents 
and 
employees, 
and 
vicariously through its staff physicians, was negligent in 
caring for her daughter.  Second, Burks accused the hospital of 
negligent infliction of emotional distress.  Third, Burks 
asserted a violation by the hospital of EMTALA by "refusing to 
provide treatment" for the baby, especially for refusing to 
resuscitate her. 
¶7 
On September 17, 1996, the Fund filed a motion for 
partial summary judgment, asking the circuit court to excuse the 
Fund from any liability for excess coverage on the third cause 
of action regarding EMTALA because the EMTALA claim was not a 
medical malpractice claim.  The court heard the Fund's motion on 
October 21, 1996, and on November 19, 1996, it issued a written 
decision which granted the motion. 
¶8 
Following the court's written decision, the parties 
entered into a stipulation and order for partial dismissal, 
which dismissed the first two causes of action in the complaint. 
 Thereafter, the only claim that remained was the EMTALA claim 
against the hospital. 
¶9 
Because the circuit court had previously granted the 
Fund's motion for partial summary judgment determining that the 
No. 97-0466  
 
4 
Fund did not provide coverage for EMTALA violations, the Fund 
submitted an order for judgment and judgment to the court, 
asking that the Fund be dismissed entirely from the case.  The 
order for judgment and judgment were both entered on January 21, 
1997.  St. Joseph's Hospital filed a Notice of Appeal from a 
final judgment on February 10, 1997. 
¶10 The court of appeals reversed the decision of the 
circuit court and concluded that the Fund must provide coverage 
for EMTALA violations.  The majority opinion, authored by Judge 
Charles Schudson, relied primarily on Wis. Admin. Code § Ins 
17.35(2)(a) 
which 
requires 
that 
a 
health 
care 
liability 
insurance policy include "[c]overage for providing or failing to 
provide health care services to a patient."  Because the cause 
of action regarding a violation of EMTALA alleged that St. 
Joseph's Hospital failed to provide certain health care services 
to a patient, the court of appeals determined that such a 
violation should be covered by the Fund. 
¶11 Judge Schudson also wrote a concurring and dissenting 
opinion, signaling that the issue was close and difficult.  He 
stated that McEvoy v. Group Health Cooperative, 213 Wis. 2d 507, 
570 N.W.2d 397 (1997), was the controlling authority.  Judge 
Schudson argued that in McEvoy this court stated that chapter 
655, the chapter under which the Fund operates, covers only 
medical malpractice claims.  Because the remaining claim was for 
a violation of EMTALA, not a medical malpractice claim, the 
concurring/dissenting opinion would have affirmed the circuit 
court's entry of judgment in favor of the Fund. 
No. 97-0466  
 
5 
¶12 We granted the Fund's petition for review to consider 
whether the Fund is required to provide excess coverage for 
damages resulting from a hospital's refusal or failure to 
provide care to a severely premature infant, an alleged 
violation of the EMTALA statute. 
ANALYSIS 
¶13 We begin with a review of the state and federal 
statutory provisions at issue in this case. 
¶14 The 
Wisconsin 
legislature 
created 
the 
Wisconsin 
Patients Compensation Fund in 1975.  § 9, chapter 37, Laws of 
1975.4  The Fund was created "for the purpose of paying that 
portion of a medical malpractice claim which is in excess of the 
limits expressed in s. 655.23(4)5 or the maximum liability limit 
                     
4 The Wisconsin Patients Compensation Fund is a subchapter 
of Wis. Stat. ch. 655, "Health Care Liability and Patients 
Compensation."  Chapter 655 "regulates claims made against 
individual health care providers and entities providing health 
care services through their employees."  McEvoy v. Group Health 
Cooperative, 213 Wis. 2d 507, 528, 570 N.W.2d 397 (1997).  
5 Wisconsin Stat. § 655.23(4) (1995-96) provides: 
Health care liability insurance, self-insurance or a 
cash or surety bond under sub. (3)(d) shall be in 
amounts of at least $200,000 for each occurrence and 
$600,000 per year for all occurrences in any one 
policy year for occurrences before July 1, 1987, 
$300,000 for each occurrence and $900,000 for all 
occurrences in any one policy year for occurrences on 
or after July 1, 1987 and before July 1, 1988, and 
$400,000 for each occurrence and $1,000,000 for all 
occurrences in any one policy year for occurrences on 
or after July 1, 1988. 
 
All references to the Wisconsin Statutes are to the 1995-96 
version unless otherwise noted. 
No. 97-0466  
 
6 
for which the health care provider is insured, whichever limit 
is greater . . ."  Wis. Stat. § 655.27(1).  In other words, 
"Chapter 655 created the Fund to curb the rising costs of health 
care by financing part of the liability incurred by health care 
providers as a result of medical malpractice claims."  Patients 
Compensation Fund v. Lutheran Hospital-LaCrosse, Inc., 223 Wis. 
2d 439, 452, 588 N.W.2d 35 (1999).  It is the responsibility of 
the health care provider to provide coverage for medical 
malpractice claims up to the amounts set out in § 655.23(4) 
through its own health care liability insurance, self-insurance, 
or a cash or surety bond. 
¶15 Congress enacted EMTALA as part of the Comprehensive 
Omnibus Budget Reconciliation Act of 1985 (COBRA) to prevent 
"patient 
dumping"i.e., 
refusing 
medical 
treatment 
or 
transferring indigent and uninsured patients from private to 
public hospitals to avoid the costs of treatment.  Marshall on 
Behalf of Marshall v. East Carroll Parish Hosp. Service Dist., 
134 F.3d 319, 322 (5th Cir. 1998).   EMTALA provides that 
hospitals that have entered into Medicare provider agreements6 
                                                                  
  
6 42 
U.S.C. 
§ 1395dd(d)(1)(A) 
provides 
that 
"[a] 
participating hospital that negligently violates a requirement 
of this section is subject to a civil money penalty . . ."  In 
addition, "[a]ny individual who suffers personal harm as a 
direct result of a participating hospital's violation of a 
requirement of this section may, in a civil action against the 
participating hospital, obtain those damages available for 
personal injury under the law of the State in which the hospital 
is located . . ."  42 U.S.C. § 1395dd(d)(2)(A).  "Participating 
hospital" is defined as a "hospital that has entered into a 
provider agreement under section 1395cc of this title."  42 
U.S.C. § 1395dd(e)(2). 
No. 97-0466  
 
7 
are prohibited from inappropriately transferring or refusing to 
provide medical care to "any individual" with an emergency 
medical condition.  42 U.S.C. § 1395dd(a).7  It "places 
obligations of screening and stabilization upon hospitals and 
emergency 
rooms 
who 
receive 
patients 
suffering 
from 
an 
'emergency medical condition.'"  Roberts v. Galen of Virginia, 
Inc., U.S., 119 S.Ct. 685, 142 L.E.2d 648 (1999) (per 
curiam). 
¶16 Under EMTALA, hospitals with emergency departments 
that have entered into Medicare provider agreements have two 
obligations.  First, if any individual comes to the emergency 
department requesting examination or treatment, a hospital must 
provide for "an appropriate medical screening examination within 
the capability of the hospital's emergency department."  42 
U.S.C. § 1395dd(a).  Second, if the hospital "determines that 
the individual has an emergency medical condition," it must 
provide "within the staff and facilities available at the 
                     
7 42 U.S.C. § 1395dd(a) provides: 
(a) Medical screening requirement 
 
In the case of a hospital that has a hospital 
emergency department, if any individual (whether or 
not eligible for benefits under this subchapter) comes 
to the emergency department and a request is made on 
the individual's behalf for examination or treatment 
for a medical condition, the hospital must provide for 
an appropriate medical screening examination within 
the capability of the hospital's emergency department, 
including ancillary services routinely available to 
the emergency department, to determine whether or not 
an emergency medical condition (within the meaning of 
subsection (e)(1) of this section) exists. 
No. 97-0466  
 
8 
hospital" for "such treatment as may be required to stabilize 
the medical condition" and may not transfer such a patient until 
the condition is stabilized or other statutory criteria are 
fulfilled.  42 U.S.C. §§ 1395dd(b),8 (c).9 
                     
8 42 U.S.C. § 1395dd(b)(1) provides: 
(b)  Necessary stabilizing treatment for emergency 
medical conditions and labor 
 
(1)  In general 
 
If any individual (whether or not eligible for 
benefits 
under 
this 
subchapter) comes 
to 
a 
hospital and the hospital determines that the 
individual has an emergency medical condition, 
the hospital must provide either 
 
(A) 
within 
the 
staff 
and 
facilities 
available at the hospital, for such further 
medical examination and such treatment as 
may be required to stabilize the medical 
condition, or 
 
(B) 
for transfer of 
the 
individual to 
another medical facility in accordance with 
subsection (c) of this section. 
 
9 42 U.S.C. § 1395dd(c)(1) provides: 
(c) Restricting transfers until individual stabilized 
 
(1) Rule 
 
If an individual at a hospital has an emergency 
medical condition 
which 
has 
not 
been 
stabilized 
(within the meaning of subsection (e)(3)(B) of this 
section), the hospital may not transfer the individual 
unless 
 
(A)(i) the individual (or a legally responsible 
person acting on the individual's behalf) after 
being informed of the hospital's obligations 
under this section and of the risk of transfer, 
No. 97-0466  
 
9 
¶17 A person who "suffers personal harm as a direct 
result" of a hospital's failure to meet the requirements under 
EMTALA may bring a civil action seeking damages and appropriate 
equitable relief against the participating hospital.  42 U.S.C. 
§ 1395dd(d)(2)(A). 
¶18 The 
relationship 
between 
chapter 
655 
and 
EMTALA 
presents an important issue for this court.  To what extent do 
these two statutes intersect?  To what extent, if any, does a 
                                                                  
in writing requests transfer to another medical 
facility, 
 
(ii) a physician (within the meaning of section 
1395x(r)(1) 
of 
this 
title) 
has 
signed 
a 
certification that based upon the information 
available at the time of transfer, the medical 
benefits reasonably expected from the provision 
of 
appropriate 
medical 
treatment 
at 
another 
medical facility outweigh the increased risks to 
the individual and, in the case of labor, to the 
unborn child from effecting the transfer, or 
 
(iii) if a physician is not physically present in 
the 
emergency 
department 
at 
the 
time 
an 
individual is transferred, a qualified medical 
person 
(as 
defined 
by 
the 
Secretary 
in 
regulations) has signed a certification described 
in clause (ii) after a physician (as defined in 
section 
1395x(r)(1) 
of 
this 
title), 
in 
consultation with 
the person, has 
made the 
determination 
described 
in 
such 
clause, 
and 
subsequently countersigns the certification; and 
 
(B) the transfer is an appropriate transfer 
(within the meaning of paragraph (2)) to that 
facility. 
 
A certification described in clause (ii) or (iii) of 
subparagraph (A) shall include a summary of the risks 
and benefits upon which the certification is based. 
No. 97-0466  
 
10
federal EMTALA claim come under Wisconsin's Patient Compensation 
Fund, so that the Fund is required to pay excess liability for 
an EMTALA violation? 
¶19 The Fund asserts that its coverage is limited to 
medical malpractice claims and that a tort claim for medical 
malpractice under state law is separate and distinct from an 
EMTALA claim grounded in federal statute.  Consequently, the 
Fund argues that it has absolutely no responsibility to cover 
any EMTALA violation. 
¶20 The Fund cites McEvoy v. Group Health Coop. of Eau 
Claire, 213 Wis. 2d 507, 570 N.W.2d 397 (1997), to support its 
position.  In McEvoy, this court examined the scope and 
application of chapter 655 to determine whether the chapter 
precluded Fund coverage for a "bad faith" tort claim against an 
HMO.  In holding that such a claim was precluded, this court 
said that "an examination of the language of chapter 655 reveals 
that the legislature did not intend to go beyond regulating 
claims for medical malpractice."  Id. at 529.  "We conclude that 
ch. 655 applies only to negligent medical acts or decisions made 
in the course of rendering professional medical care."  Id. at 
530. 
¶21 The Fund relies on several cases for the proposition 
that EMTALA is not a federal malpractice act.  Brooks v. 
Maryland General Hosp., Inc., 996 F.2d 708, 710 (4th Cir. 1993); 
Reynolds v. Mercy Hosp., 861 F. Supp. 214, 219 (W.D.N.Y. 1994). 
 A hospital's liability is not grounded upon tort concepts.  
Griffith v. Mt. Carmel Medical Center, 842 F. Supp. 1359, 1365 
No. 97-0466  
 
11
(D. Kan. 1994).  EMTALA, the Fund argues, is a strict liability 
law created to prevent patient dumping, without any regard to 
whether malpractice occurred. 
¶22 The Fund also claims that providing coverage under the 
Fund for EMTALA violations conflicts with Rineck v. Johnson, 155 
Wis. 2d 659, 456 N.W.2d 336 (1990), which it says makes clear 
that for other statutes to apply to the Fund they must be 
specifically incorporated into chapter 655. 
¶23 Finally, the Fund argues that it is error to conclude 
that Wis. Admin. Code § Ins. 17.35(2)(a),10 and therefore chapter 
655, applies any time there is liability for providing or 
failing to provide health care services to a patient, regardless 
of whether there is medical malpractice.  The Fund asserts that 
§ Ins 17.35(2)(a) applies to medical malpractice cases only, 
since the rule implements Wis. Stat. § 655.23.  The rule is 
limited 
to 
what 
§ 655.23 
coversinsurance 
for 
medical 
malpractice claims. 
                     
10 Wis. Admin. § Ins. 17.35 provides in part: 
Primary 
coverage; 
requirements; 
permissible 
exclusions; deductibles.  (1) PURPOSE.  This section 
implements ss. 631.20 and 655.24, Stats., relating to 
the approval of policy forms for health care liability 
insurance subject to s. 655.23, Stats. 
 
(2)  REQUIRED COVERAGE.  To qualify for approval under 
s. 631.20, Stats., a policy shall at a minimum provide 
all of the following: 
 
(a)  Coverage for providing or failing to provide 
health care services to a patient. 
No. 97-0466  
 
12
¶24 In sum, the Fund asserts EMTALA is a federal statute 
that 
"imposes 
two 
requirements 
on 
any 
hospital 
which 
participates in the Medicare program:  (1) the hospital must 
conduct appropriate medical screening to persons visiting the 
hospital's emergency room; and (2) the hospital may not . . . 
transfer out of the hospital a patient whose medical condition 
has not been stabilized."  Brewer v. Miami County Hosp., 862 F. 
Supp. 305, 307 (D. Kan. 1994).  A malpractice claim requires a 
violation of a standard of care.  This requires negligence.  An 
action under EMTALA requires proof of a violation of the federal 
statute, nothing more.  Consequently, the Fund argues that no 
EMTALA violations come under the Fund. 
¶25 St. Joseph's Hospital takes exactly the opposite 
position.  It asserts that all violations of EMTALA must be 
covered by the Fund.  "EMTALA claims are failure to treat 
claims," St. Joseph's argues.  "They all involve allegations of 
inadequate or inappropriate medical care against hospitals that 
pay assessments to the Fund with the reasonable expectation of 
coverage for such claims."  Respondent's Br. at 4.  Because 
EMTALA claims are not unlike medical malpractice claims, St. 
Joseph's declares, the legislature intended to provide coverage 
for an allegation that a health care provider failed to examine 
or stabilize a patient. 
¶26 St. Joseph's Hospital maintains that chapter 655 does 
not define "medical malpractice" and does not consistently refer 
to coverage only for "medical malpractice."  It cites several 
examples of other language in chapter 655 such as Wis. Stat. 
No. 97-0466  
 
13
§ 655.017 (limitation on noneconomic damages applies to "damages 
recoverable by a claimant or plaintiff under this chapter for 
acts or omissions of a health care provider . . .") and 
§ 655.27(1) ("The fund shall provide occurrence coverage for 
claims against health care providers that have complied with 
this chapter . . .").  It also asserts that because EMTALA is 
interpreted to incorporate state medical malpractice damage 
caps, the federal statute should also be interpreted to 
incorporate Wisconsin's requirement that the Fund cover claims 
against health care providers who comply with chapter 655. 
¶27 St. Joseph's Hospital also cites Wis. Admin. § Ins 
17.35(2)(a) in support of its position.  According to St. 
Joseph's, because § Ins 17.35(2)(a) defines the minimum coverage 
a primary health care liability policy must contain, the Fund, 
which provides excess coverage, should not provide less coverage 
than the provider's primary insurer.  
¶28 St. Joseph's Hospital distinguishes Rineck and McEvoy: 
 Rineck did not say anything about the extent of the Fund's 
coverage obligations but instead held that the Fund supersedes 
any contrary rule in other statutes or the common law.  McEvoy 
never addressed the extent of the Fund's coverage obligations or 
whether the Fund covers EMTALA claims but instead addressed the 
issue whether the denial of HMO benefits is a chapter 655 
medical malpractice claim. 
¶29 St. Joseph's Hospital points out that McEvoy dealt 
with an administrative decision to deny coverage for health care 
services, while this case involves an allegedly "improper 
No. 97-0466  
 
14
medical action or decision" made in the course of rendering 
professional care.  St. Joseph's stresses that this case is not 
an administrator's breach of contract, as in McEvoy, but a 
health care provider's medical decision that medical treatment 
was not appropriate and should not be rendered.  
¶30 In sum, St. Joseph's asserts that the Fund was created 
to address the increase in claims arising out of the delivery of 
health care services.  EMTALA claims arise out of the delivery 
or failure to deliver health care services.  Hence, St. Joseph's 
argues that all EMTALA claims come under the Fund. 
¶31 Both parties make compelling arguments, and both 
parties can point to cases from other jurisdictions to support 
their respective positions. 
¶32 Our ultimate objective in this case is to interpret 
the 
scope 
of 
chapter 
655, 
a 
Wisconsin 
statute. 
 
The 
interpretation and application of a statute presents a question 
of law that this court reviews de novo.  Patients Compensation 
Fund v. Lutheran Hospital, 223 Wis. 2d at 454; Wisconsin Patient 
Compensation Fund v. Wisconsin Health Care Liab. Ins. Plan, 200 
Wis. 2d 599, 606, 547 N.W.2d 578 (1996). 
PATIENTS COMPENSATION FUND 
¶33 The 
Patients 
Compensation 
Fund 
provides 
excess 
coverage for medical malpractice claims.  Wisconsin Stat. § 
655.27(1) provides: 
 
There is created a patients compensation fund for the 
purpose 
of 
paying 
that 
portion 
of 
a 
medical 
malpractice claim which is in excess of the limits 
expressed in s. 655.23(4) or the maximum liability 
No. 97-0466  
 
15
limit for which the health care provider is insured, 
whichever limit is greater, paying future medical 
expense payments under s. 655.015 and paying claims 
under sub. (1m).  The fund shall provide occurrence 
coverage for claims against health care providers that 
have complied with this chapter, and against employes 
of those health care providers, and for reasonable and 
necessary expenses incurred in payment of claims and 
fund administrative expenses. . . .  (Emphasis 
supplied). 
¶34 In McEvoy, after citing five references to malpractice 
in the chapter, this court said:  "We conclude that ch. 655 
applies only to negligent medical acts or decisions made in the 
course of rendering professional medical care.  To hold 
otherwise would exceed the bounds of the chapter and would grant 
seeming immunity from non-ch. 655 suits to those with a medical 
degree."  McEvoy, 213 Wis. 2d at 530. 
¶35 We know that chapter 655 applies only to medical 
malpractice claims, but this begs the question.  What is a 
medical malpractice claim?  Chapter 655 does not define medical 
malpractice.  The Wisconsin Jury InstructionCivil 1023 states 
that the standard to determine medical malpractice is "whether 
(doctor) failed to use the degree of care, skill, and judgment 
which reasonable (general practitioners) (specialists) would 
exercise given the state of medical knowledge at the time of the 
(treatment) (diagnosis) in issue." 
¶36 The phrase "state of medical knowledge at the time of" 
in the instruction implies that the standard of care for general 
practitioners or specialists is constantly evolving as the state 
of medical knowledge advances.  Cf. Nowatske v. Osterloh, 198 
Wis. 2d 419, 438-39, 543 N.W.2d 265 (1996).  The state of 
No. 97-0466  
 
16
medical 
knowledge 
is 
not 
static. 
 
It 
may 
in 
certain 
circumstances 
require 
an 
understanding 
of 
statutory 
requirements.  The Informed Consent Statute is one example.  See 
Wis. Stat. § 448.30. 
¶37 The failure to provide health care services can be a 
component of medical malpractice.  Wisconsin Stat. § 655.005(1) 
refers to "damages for bodily injury or death due to acts or 
omissions . . ." and subsection (2) refers to "claims against 
the health care provider or the employe of the health care 
provider due to the acts or omissions of the employe acting 
within the scope of his or her employment and providing health 
care 
services." 
 
(Emphasis 
supplied). 
 
Wisconsin 
Stat. 
§ 655.44(1) refers to persons having "a claim or a derivative 
claim under this chapter for bodily injury or death because of a 
tort . . . based on professional services rendered or that 
should have been rendered by a health care provider . . ."  
(Emphasis supplied). 
¶38 Given this statutory language it makes perfect sense 
for Wis. Admin. § Ins 17.35(2)(a) to require that a health care 
liability insurance policy, providing the primary coverage for a 
health care provider, include "[c]overage for providing or 
failing to provide health care services to a patient." 
¶39 In Steinberg v. Arcilla, 194 Wis. 2d 759, 773, 535 
N.W.2d 444 (Ct. App. 1995), the court of appeals accepted a jury 
instruction which read in part: 
 
A physician fails to exercise reasonable and ordinary 
care when, without intending to do any wrong, he does 
No. 97-0466  
 
17
an act or omits to act under circumstances in which a 
physician ought reasonably to foresee that such action 
or 
omission 
will 
subject 
his 
patient 
to 
an 
unreasonable risk [of] injury or damage.  (Emphasis 
supplied). 
This instruction is cited by this court in Notwatske, 198 Wis. 
2d at 434-35 n.8. 
 
¶40 Medical malpractice includes omissions, failures to 
provide health care services, and professional services that 
should have been rendered when these deficiencies violate the 
standard of care required from a health care provider.  The 
failure to provide health care services to a patient can, in 
appropriate circumstances, be negligence. 
EMTALA 
 
¶41 The announced objective of EMTALA was to prohibit 
hospitals that receive Medicare funds from engaging in "patient 
dumping."  Elizabeth Larson, Note, Did Congress Intend to Give 
Patients The Right to Demand and Receive Inappropriate Medical 
Treatments?:  EMTALA Reexamined in Light of Baby K, 1995 Wis. L. 
Rev. 1425.  "Patient dumping is the refusal by a hospital to 
provide necessary emergency medical treatment to someone based 
upon that person's inability to pay."  Id. 
 
¶42 While Congress may have intended to focus on the 
indigent and uninsured when it passed EMTALA, the language it 
used was conducive to a much broader interpretation.  In recent 
years EMTALA has been construed to apply to all patients, 
No. 97-0466  
 
18
irrespective of their ability to pay.11  Most courts that have 
considered the question have ruled that EMTALA does not contain 
an express or implied "improper motive" requirement.12  A person 
need not show any medical malpractice to prove an EMTALA 
violation.  In fact, two courts have required medical treatment 
outside the prevailing standard of care, treatment that is at 
least arguably medically inappropriate.13 
 
¶43 In a persuasive article, Elizabeth A. Larson writes 
that even the fully insured may bring suit under EMTALA. 
 
However, with the element of economic discrimination 
absent from such a case, it is difficult to determine 
exactly what role EMTALA should play.  The courts . . 
. have established a variety of tests for finding a 
violation in such cases.  While these tests differ 
from one another, they share a common goal:  to 
determine whether a particular hospital failed to 
                     
11  See, e.g., Collins v. DePaul Hosp., 963 F.2d 303, 308 
(10th Cir. 1992); Brooker v. Desert Hosp. Corp., 947 F.2d 412, 
414 (9th Cir. 1991); Gatewood v. Washington Healthcare Corp., 
933 F.2d 1037, 1039 (D.C. Cir. 1991); Cleland v. Bronson 
HealthCare Group, 917 F.2d 266, 269-70 (6th Cir. 1990); Deberry 
v. Sherman Hosp. Ass'n, 741 F. Supp. 1302, 1303 (N.D. Ill. 
1990). 
12 See, e.g., Collins, 963 F.2d at 308; Brooker, 947 F.2d at 
414; Gatewood, 933 F.2d at 1040; Deberry, 741 F. Supp. at 1306. 
 See also Roberts v. Galen of Virginia, Inc., U.S., 119 S. 
Ct. 685, 687, 142 L.E.2d 648 (1999). 
13 In re Baby K, 16 F.3d 590 (4th Cir. 1994); In re Baby K, 
832 F. Supp. 1022 (E.D. Vir. 1993). 
The Baby K case caused a sensation because the court held 
that to the extent that state law exempted physicians from 
providing care they considered medically inappropriate, it 
conflicted 
with 
EMTALA 
provisions 
requiring 
continuous 
stabilizing treatment for emergency patients and was thus 
preempted by EMTALA. 
No. 97-0466  
 
19
adequately screen the patient for an emergency medical 
condition and, if such a condition was found, whether 
the 
hospital 
stabilized 
it 
before 
releasing 
or 
transferring the patient. 
 
The 
goal 
of 
these 
tests 
is 
effectively 
indistinguishable from that of state malpractice laws: 
 to determine whether the established standard of care 
was breached.  But while the common law of malpractice 
takes individual factors into account, EMTALA is 
brief, vaguely written, and provides no guidance for 
determining a standard of care. 
Larson, 1995 Wis. L. Rev. at 1426-27 (emphasis supplied). 
 
¶44 Larson writes that "The majority rule . . . holds that 
EMTALA does not guarantee a correct diagnosis and that EMTALA 
does not create a federal malpractice law.  Despite the courts' 
claims, plaintiffs seem to have noticed that the majority rule 
does in effect create a federal malpractice law."  Id. at 1457. 
 
¶45 Larson is not the only commentator to suggest that 
EMTALA has made incursions into traditional areas of state 
malpractice law.  Congress has created "a federal standard for 
emergency care."  Scott B. Smith, The Critical Condition of the 
Emergency Medical Treatment and Active Labor Act:  A Proposed 
Amendment to the Act After In the Matter of Baby K, 48 Vand. L. 
Rev. 1491, 1507 (1995).  "COBRA's imposition of federal 
standards on the states represents a radical change from the 
status quo.  Previously state and local governments generally 
determined the regulation of emergency care."  Karen I. Treiger, 
Preventing Patient Dumping:  Sharpening the COBRA's Fangs, 61 
N.Y.U. L. Rev. 1186, 1209 (1986). 
 
¶46 "In the broadest terms, EMTALA imposes a legal duty on 
hospitals pertaining to the care and subsequent transfer of 
No. 97-0466  
 
20
individuals with emergency medical conditions."  Alicia Dowdy, 
et al., The Anatomy of EMTALA:  A Litigator's Guide, 27 St. 
Mary's L.J. 463, 470 (1996).  "Courts determining the standard 
of liability under EMTALA have looked to and applied the duties 
outlined by the statute itself.  When a statute like EMTALA 
creates a duty of care, a violation of the statutory duty is 
categorized as 'negligence per se' or 'statutory liability.'"  
Id. at 489.  
 
EMTALA imposes a duty on hospitals regarding emergency 
department screening, actual knowledge of medical 
conditions, stabilization, and transfer, and courts 
have noted that the statute itself describes the type 
of conduct required with respect to each of these 
provisions.  Thus, in determining whether a hospital 
has departed from the statutorily imposed duties, 
courts reduce the statute to its elements and examine 
the duty of care for each element. 
Id. at 489-90. 
 
¶47 There is ample evidence that medical malpractice 
claims and EMTALA claims are being filed in the same lawsuit.14  
Multiple claims have been encouraged.15  State and federal courts 
                     
14 Collins, 963 F.2d at 308; Gatewood, 933 F.2d at 1039; 
Power v. Arlington Hosp., 800 F. Supp. 1384, 1389 n.15 (E.D. Va. 
1992), aff'd, 42 F.3d 851 (4th Cir. 1994); Coleman v. McCurtain 
Memorial Medical Management, Inc., 771 F. Supp. 343, 344 (E.D. 
Okla. 1991), overruled by Collins, 963 F.2d 303; Deberry, 741 F. 
Supp. at 1303; Nichols v. Estabrook, 741 F. Supp. 325, 326 
(D.N.H. 1989); Evitt v. University Heights Hosp., 727 F. Supp. 
495, 498 (S.D. Ind. 1989). 
15 Mark R. Bower & Charles S. Gucciardo, Proving A Separate 
Cause of Action in Malpractice Cases for Violation of the 
Federal "Anti-Dumping" Act, VERDICTS, SETTLEMENTS & TACTICS, May 
1994, at 147.  
No. 97-0466  
 
21
have concurrent jurisdiction over EMTALA claims.16  "It is 
hornbook law that district courts have discretion to exercise 
supplemental jurisdiction over the state law claims where the 
state and federal claims derive from a common nucleus of 
operative facts."  Lopez-Soto v. Hawayek, 988 F. Supp. 41, 46 
(D.P.R. 1997) (citing 28 U.S.C. § 1367 and United Mine Workers 
v. Gibbs, 383 U.S. 715, 725 (1966)), reversed on other grounds, 
175 F.3d 170 (1st Cir. 1999). 
 
¶48 EMTALA 
violations 
frequently 
have 
a 
malpractice 
element.  See, e.g., Power v. Arlington Hospital Assoc., 42 F.3d 
851 (4th Cir. 1994);  Reid v. Indianapolis Osteopathic Med. 
Hosp., Inc., 709 F. Supp. 853, 855 (S.D. Ind. 1989); Barris v. 
County of Los Angeles, 972 P.2d 966, 972 (Cal. 1999). 
 
¶49 To illustrate, in Power v. Arlington Hospital 
Assoc., 42 F.3d 851 (4th Cir. 1994), Susan Power came to the 
Arlington Hospital emergency room complaining of pain in her 
left hip, her lower left abdomen, and in her back running down 
her leg, and reported she was unable to walk, was shaking, and 
had severe chills.  Id. at 853.  She was eventually given some 
pain medication and dismissed after seeing two nurses and two 
physicians.  Id.  She returned to the hospital the next day in 
an unstable condition with virtually no blood pressure.  Id.  
She was diagnosed as suffering from septic shock and immediately 
admitted into intensive care where she remained for over four 
months.  Id.  She eventually had both of her legs amputated 
                     
16 40A Am. Jur. 2d Hospitals and Asylums § 12 (1999).  
No. 97-0466  
 
22
below the knee, lost sight in one eye, and experienced severe 
permanent lung damage.  Id.  She was eventually transferred to a 
hospital in her hometown in England.  Id.  
¶50 Power 
sued Arlington 
Hospital alleging 
that the 
hospital 
violated 
EMTALA 
by 
failing 
to 
provide 
her 
an 
"appropriate medical screening" when she initially arrived at 
the emergency room.  Id. at 853-54.  She also claimed that the 
hospital violated EMTALA by transferring her to the hospital in 
England while she was still in an unstable condition.  Id. at 
854.  A jury returned a verdict in favor of Power on the 
appropriate medical screening claim and awarded actual damages 
of $5 million.  Id.  The jury found in favor of the hospital on 
the inappropriate transfer claim.  Id. 
¶51 The hospital appealed, raising questions about the 
appropriate legal standard for recovery in an EMTALA claim and 
EMTALA's interrelationship with a Virginia statute that caps 
damages from medical malpractice suits.  Id.  The hospital 
argued that the court of appeals should adopt a standard that 
requires proof of non-medical reason or an improper motive for a 
hospital's treatment or discharge decision before a plaintiff 
can recover for a breach of EMTALA.  Id. at 856.  The hospital 
also asserted that damages in the action should be limited by 
Virginia's malpractice damages cap.  Id. at 860. 
¶52 With respect to the claim that proof of non-medical 
reason or improper motive is required for an EMTALA claim, the 
Fourth Circuit stated: 
 
No. 97-0466  
 
23
[T]his is not a case in which the EMTALA claim is 
based 
solely 
on allegations 
that 
emergency 
room 
personnel failed to make a proper diagnosis. . . .  
Power has clearly presented evidence from which a jury 
could conclude that she was treated differently from 
other patients presenting to the Arlington Hospital 
emergency room, and that the Hospital did not apply 
its standard screening procedure, such that it was, 
uniformly.  Although the facts might also give rise to 
a 
claim 
under 
state 
law 
for 
misdiagnosis 
or 
malpractice, that is not what Power has alleged or 
argued here.  Her evidence is sufficient to meet the 
threshold requirement of an EMTALA claim, namely that 
the screening she was provided by Arlington Hospital 
deviated from that given to other patients. 
Id. at 856-57 (citation omitted). 
 
¶53 The Fourth Circuit determined that "Power's EMTALA 
claim would be deemed a malpractice claim under the Virginia 
Medical Malpractice Act, despite the fact that it does not 
allege a breach of the prevailing professional standard of care 
generally associated with a malpractice claim."  Id. at 861. 
 
¶54 Power demonstrates that the scope of EMTALA extends 
beyond a refusal to treat based on economic reasons.  The 
argument that the hospital failed to screen Power for economic 
reasons was tenuous, yet the Fourth Circuit still recognized 
that a valid EMTALA claim existed.   The potential scope of 
EMTALA is extremely broad, and is not limited to the refusal to 
provide care to persons without insurance.  See, e.g., Lopez-
Soto v. Hawayek, 175 F.3d 170 (1st Cir. 1999); Summers v. 
Baptist Medical Center Arkadelphia, 91 F.3d 1132 (8th Cir. 
1996);  Carodenuto v. New York City Health & Hospitals Corp., 
593 N.Y.S.2d 442 (N.Y. Sup. Ct. 1992). 
No. 97-0466  
 
24
 
¶55 EMTALA claims are not limited to persons who are 
indigent and uninsured.  Hospitals can violate EMTALA without 
improper motives by "negligently"17 failing to satisfy the 
standards 
of 
emergency 
care 
established 
in 
federal 
law.  
Commentators have stated that EMTALA overlaps state malpractice 
law.18  State malpractice law can include failure to provide 
health 
care 
services. 
 
Consequently, 
the 
conclusion 
is 
inescapable that at least some EMTALA violations are medical 
malpractice claims. 
 
¶56 Permitting the label on a cause of action to dictate 
whether a health care provider receives excess coverage from the 
Patients 
Compensation 
Fund 
would 
be 
elevating 
form 
over 
substance and negating the purpose of the Fund.  Hence, we look 
to the test in McEvoy and hold that when a hospital's violation 
of EMTALA results from a negligent medical act or from a 
decision made in the course of rendering professional medical 
care, the Fund has an obligation to provide excess coverage.  
Conversely, when a hospital's violation of EMTALA results from 
an economic decision, the Fund has no duty to provide coverage. 
  
¶57 In determining whether a violation of EMTALA was 
medically-based or economically-based, the first factor to 
consider is whether the patient had health care insurance 
                     
17 42 
U.S.C. 
§ 1395dd(d)(1)(A) 
provides 
that 
"A 
participating hospital that negligently violates a requirement 
of this section is subject to a civil money penalty . . ."  
18 Larson, 1995 Wis. L. Rev. at 1457.  
No. 97-0466  
 
25
coverage.  The presence of insurance coverage permits the 
inference that the violation was not economically-based.  The 
absence of coverage creates an implication that the violation 
may have been economically-based.  Other factors to consider are 
whether the patient was given screening and other medical 
treatment, whether the screening was consistent with the usual 
practice at the hospital, whether a decision to transfer was 
made in consultation with another hospital, whether the action 
complained of resulted from the decision of a doctor or an 
administrator, 
and 
whether 
the 
patient 
has 
also 
made 
a 
malpractice claim. 
¶58 Under the facts in this case, coverage under the Fund 
exists for Burks' claimed EMTALA violation.  There was testimony 
that a medical decision was made not to treat Burks' newborn 
because medically the baby could not survive.  In addition, 
several of the indicia described above existed in this case.  
Burks had medical insurance with PrimeCare Health Plan, Inc.    
Doctors made the decision not to treat Burks' newborn.  This was 
not a case in which a non-medical administrator of the hospital 
made a decision not to treat based on economics.  Burks began 
her 
suit 
claiming 
both 
an 
EMTALA 
violation 
and 
medical 
malpractice.  Without reaching the merits of Burks' EMTALA 
violation claim, we conclude that coverage under the Fund 
exists. Therefore, we affirm the decision of the court of 
appeals. 
By the Court.—The decision of the court of appeals is 
affirmed. 
No. 97-0466  
 
26
No. 97-0466.ssa 
 
1 
¶59 SHIRLEY S. ABRAHAMSON, CHIEF JUSTICE (concurring).   I 
join the mandate of the majority opinion but write separately to 
state my disagreement with the conclusion that the Wisconsin 
Patients Compensation Fund has a duty to provide excess coverage 
for "medically-based" violations of 
the federal 
Emergency 
Medical Treatment and Active Labor Act (EMTALA), but not 
"economically-based" violations.  The distinction drawn by the 
majority opinion was not raised or briefed by the parties, is 
unsupported by law and is unnecessary for the holding in this 
case. 
¶60 The EMTALA claim in this case is, as the majority 
recognizes, a failure to treat within the definition of medical 
malpractice used in the majority opinion.  See Majority op. at 
15.  Further, I conclude that the majority should hold, as St. 
Joseph's Hospital urges, that EMTALA claims are failure to treat 
claims arising out of the delivery of health care services.  
EMTALA imposes a legal duty of care on hospitals.  Both EMTALA 
and the common law of medical malpractice establish standards of 
care, the breach of which gives rise to liability.  The 
Wisconsin legislature intended the Fund to cover claims against 
hospitals 
alleging 
failure 
to 
provide 
appropriate medical 
treatment, regardless of whether the standard for treatment is 
set by common law or statute.  Accordingly, I see no basis for 
the distinction made by the majority opinion that would 
condition the Fund's duty to provide excess liability on whether 
a hospital's decision not to treat was a medical or economic 
decision. 
No. 97-0466.ssa 
 
2 
¶61 For the reasons stated, I concur.   
 
97-0466.awb 
 
1 
¶62 ANN WALSH BRADLEY, J. (Dissenting).   EMTALA is not a 
federal malpractice statute and is not designed to provide a 
federal remedy for general malpractice.19  Because the majority 
concludes otherwise, I dissent. 
¶63 The legislative history to the act indicates that 
EMTALA was enacted to prevent “‘patient dumping,’ which is the 
practice of refusing to treat [emergency care] patients who are 
unable to pay.”  Marshall v. East Carroll Parish Hospital 
Service District, 134 F.3d 319, 322 (5th Cir. 1998); see 
H.R.Rep. No. 241, 99th Cong., 1st Sess., pt. 1, at 27 (1985).  
As the Fourth Circuit explained, “[u]nder traditional state tort 
law, hospitals are under no legal duty to provide this 
[emergency] care.”  Brooks v. Maryland General Hospital, 996 
F.2d 708, 710 (4th Cir. 1993).  EMTALA imposed such a duty, but 
not one “to guarantee that all patients are property diagnosed, 
or even to ensure that they receive adequate care.”  Baker v. 
Hospital Corp. of America, 977 F.2d 872, 880 (4th Cir. 1992). 
                     
19 See, e.g., Marshall v. East Carroll Parish Hospital 
Service District, 134 F.3d 319, 322 (5th Cir. 1998); Summers v. 
Baptist Med. Center Arkadelphia, 91 F.3d 1132, 1136-37 (8th Cir. 
1996) (en banc); Vickers v. Nash General Hosp., Inc., 78 F.3d 
139, 142 (4th Cir. 1996); Correa v. Hospital San Francisco, 69 
F.3d 1184, 1192 (1st Cir. 1995), cert. denied, 517 U.S. 1136 
(1996); Eberhardt v. City of Los Angeles, 62 F.3d 1253, 1255, 
1258 (9th Cir. 1995); Urban By and Through Urban v. King, 43 
F.3d 523, 525 (10th Cir. 1994); Holcomb v. Monahan, 30 F.3d 116, 
117 & n. 2 (11th Cir. 1994); Gatewood v. Washington Healthcare 
Corp., 933 F.2d 1037, 1038-39 (D.C. Cir. 1991); Cleland v. 
Bronson Health Care Group, Inc., 917 F.2d 266, 268, 272 (6th 
Cir. 1990). 
97-0466.awb 
 
2 
¶64 In direct contrast, this court has concluded that the 
Patients Compensation Fund “applies only to negligent medical 
acts or decisions made in the course of rendering professional 
medical care.”  McEvoy v. Group Health Coop. of Eau Claire, 213 
Wis. 2d 507, 570 N.W.2d 397 (1997); see also Wisconsin Patient’s 
Compensation Fund v. WHCLIP, 200 Wis. 2d 599, 607, 547 N.W.2d 
578 (1996); State ex rel. Strykowski v. Wilkie, 81 Wis. 2d 491, 
499-500, 261 N.W.2d 434 (1978).  As a result, “claims not based 
on malpractice, such as a bad faith tort action, survive 
application of [the] chapter” creating the Fund.  McEvoy, 213 
Wis. 2d at 530. 
¶65 In light of these cases, I can come to no other 
conclusion than this:  EMTALA covers “patient dumping” but not 
medical malpractice, and the Fund covers medical malpractice but 
not “patient dumping.”  Burks’ remaining claim was based on a 
violation of EMTALA.  The court had already dismissed her two 
medical malpractice claims.   
¶66 Under 
our 
binding 
precedent 
combined 
with 
the 
persuasive precedent of other jurisdictions, the Fund is not an 
“excess liability insurance carrier” for causes of action 
stemming from an EMTALA violation.  Patient’s Compensation Fund 
v. Lutheran Hospital, 223 Wis. 2d 439, 452, 588 N.W.2d 35 
(1999).  Accordingly, I dissent. 
 
 
97-0466.awb 
 
1