Opinion ID: 6108497
Heading Depth: 1
Heading Rank: 4

Heading: this court reaffirms the constitutional validity of requiring an affidavit from a qualified health care provider

Text: Mahoney is directly on point and controlling here. In Mahoney , the plaintiffs' malpractice claim was dismissed after they failed to submit an affidavit of merit within the time limits set by section 538.225. 807 S.W.2d at 505 . The plaintiffs argued the 'screening' process of § 538.225 that requires 'a health care provider's written report' not only violates the guarantee that courts be open 'without denial or delay[ ]' but also imposes an unreasonable precondition to free access to the courts and so to the right to trial by jury. Id. at 509 . This Court disagreed, holding the right of access to the courts means simply the right to pursue in the courts the causes of action the substantive law recognizes. Id. at 510 . In medical malpractice actions, the substantive law requires a plaintiff to prove by a qualified witness that the defendant deviated from an accepted standard of care. Without such testimony, the case can neither be submitted to the jury nor be allowed to proceed by the court. Id. And, Mahoney held, the affidavit requirement is consistent with this substantive law because the purpose of requiring an affidavit of merit under section 538.225 is to prevent frivolous medical malpractice lawsuits when a plaintiff cannot put forth adequate expert testimony to support their claims. Id. For this reason, this Court held section 538.225 's affidavit requirement denies no fundamental right, but at most merely [re]design[s] the framework of the substantive law to accomplish a rational legislative end, id. at 510 , of protect[ing] the public and litigants from the cost of ungrounded medical malpractice claims, id. at 507 (citation and quotations omitted). For similar reasons, this Court rejected the argument that section 538.225 's affidavit requirement violates the right to trial by jury, stating it is not the 'screening' procedure of § 538.225 that impedes the progression of [a plaintiff's] petition to the jury ... but their failure to meet a requirement of substantive law. Id. at 508 . Mahoney noted Rule 55.03 requires of the party or attorney the duty of reasonable inquiry that the petition or other paper filed 'is well grounded in fact and is warranted by existing law.'  Id. In the same way, Mahoney held, the affidavit requirement simply ensures that a party who sues for the malpractice of a health care provider has by a reasonable inquiry come to a reasonable belief that the petition is warranted by the proof and the law. Id. Mahoney also compared the affidavit requirement to traditionally recognized procedures such as a directed verdict or summary judgment, and rejected the jury trial challenge because the affidavit requirement simply parallels the practice already prescribed for all civil actions, and is hardly  more onerous to the right to trial by jury. Id. This Court also rejected the Mahoney plaintiffs' argument the affidavit requirement invades the judicial function by having a health care provider rather than a judicial officer determine the validity of [a plaintiff's] cause of action. Id. at 510 . Rather, this Court held dismissing a claim for lack of compliance with section 538.225is a determination that under the substantive law of medical malpractice the petition cannot succeed, and so is frivolous. It is a judge that decides that the case may not proceed, not a health care provider. Id. Ms. Hink does not dispute Mahoney so held nor does she suggest it should be overruled. Rather, in oral argument, and implicit in the argument section of her brief, is her suggestion Mahoney can be distinguished because, at the time it was decided, section 538.225 simply said a judge may dismiss a case for the failure to file an affidavit of merit, whereas now, as a result of a 2005 amendment, section 538.225 provides the judge shall dismiss the case if plaintiff fails to file an affidavit of merit. Mahoney did not base its ruling on the statute's use of the word may, however, and this Court does not agree the change from may to shall affects the open courts and jury trial rights. While previously a judge did not have to dismiss the suit when an affidavit was not provided, the trial judge in Mahoney did dismiss the suit precisely for that failure. The analysis in Mahoney , therefore, focused on whether dismissal for failure to file an affidavit constitutes denial of the right to jury trial or violates the open courts provision or separation of powers principles, just as is alleged here. Accordingly, Mahoney 's analysis is directly applicable without regard to the change from may to shall. Ms. Hink argues another change in the statute adopted in 2005 raises an issue not addressed in Mahoney and dispositive here. In addition to changing may to shall, the 2005 amendment to section 538.225 for the first time defined legally qualified healthcare providers to include only those who practice in substantially the same specialty as the defendant. Ms. Hink argues this new limitation on who can provide the requisite opinion supporting an affidavit of merit imposes a stricter burden on the plaintiff than is required to prove a prima facie case of negligence at trial. At trial, a medical malpractice plaintiff bringing a claim of negligence can make a prima facie case through expert testimony from any qualified expert, regardless of whether the expert practices in substantially the same specialty as the defendant. See Klotz v. St. Anthony's Med. Ctr., 311 S.W.3d 752 , 761 (Mo. banc 2010) (rejecting the notion that proving standard of care requires that expert testimony at trial be limited to persons in the defendant's specialty). This means a plaintiff might be out of court because he or she is unable to provide an affidavit of merit from a physician in substantially the same specialty even though the plaintiff could make a submissible case if the affidavit requirement did not exist. But this argument fails to recognize this Court has held a health care provider may have a different board certification but may practice 'substantially the same specialty' because of an expertise in the medical procedure at issue. Many medical procedures are not peculiar to one board certification. Spradling, 313 S.W.3d at 689 . In most cases, therefore, this Court's interpretation of substantially the same specialty, which includes persons qualified by expertise rather than board certification, means the same experts would qualify under either standard.  Ms. Hink posits there nonetheless may be some instances in which an expert could not arguably be considered even substantially in the same specialty yet would be considered a qualified trial expert. She suggests this may be the case, for instance, in the case of the family doctor, who may not be considered a specialist of any sort, or in the case of a failure by such a doctor to diagnose cancer, in which case an oncologist might need to be called, and the latter would be in a different specialty. As just noted, under Spradling, when the expert has gained the requisite expertise through experience, then it would not matter that he or she practiced in different fields. Ms. Hink suggests there may nonetheless be exceptions, particularly in cases that are so complex the plaintiff may need to rely on unique or multiple experts in different fields at trial, including fields not related to that of the defendant's practice, to show damages or to support a complex theory of causation. Some of those experts would likely be in different specialties from the defendant. Even worse, Ms. Hink argues, compliance with the statute may prohibit her from relying on multiple experts at all, for she reads its use of the phrase legally qualified health care provider to mean a plaintiff must rely on a single health care provider to support standard of care, causation, and damages of all types and all theories. This, she says, is an arbitrary additional requirement and, in a complex case, may require dismissal of an otherwise meritorious case. These indeed are issues different than those rejected in Mahoney. There, the Court found the affidavit requirement constitutional because it simply required plaintiffs to show what the substantive law already requires-there exists a qualified witness [who will attest] that the defendant deviated from an accepted standard of care. 807 S.W.2d at 510 . This did not violate the right to jury trial or open courts or the separation of powers because, Without such testimony, the case can neither be submitted to the jury nor be allowed to proceed by the court. Id . Mahoney did not suggest the legislature could add a requirement that would preclude an otherwise meritorious, submissible case from going to trial because of the inability to find an expert to testify to a matter not required to be shown to submit a cause of action. Here, however, Ms. Hink has failed to show section 538.225 imposes such requirements. Nothing in section 538.225 provides the affidavit may rely on only a single expert opinion on all issues. Section 538.225 simply provides a plaintiff shall file an affidavit with the court stating that he or she has obtained the written opinion of a legally qualified health care provider as to the defendant's breach of the standard of care and causation. While the statute uses the term a legally qualified health care provider, Missouri law expressly provides the singular includes the plural unless otherwise stated. 4 Any requirement in this case that the entire breach of standard of care and causation be proven by a single expert appears to have been self-imposed. Further, nothing in section 538.225 provides every single element of damage claimed must be supported in the opinion that forms the basis of the affidavit, as Ms.Hink  suggests she was unable to accomplish. Neither does Mahoney support such a reading of the statute. To the contrary, Mahoney says the purpose of the affidavit requirement is to allow the early dismissal of frivolous claims. 807 S.W.2d at 507 . That purpose necessarily is served if the plaintiff files an affidavit stating he or she has the opinion of a qualified health care provider that the defendant failed to meet the standard of care, caused the injury, and damages resulted. Whether every theory or every claimed item of damage later is found to be submissible need not be determined in deciding whether the action itself is frivolous, and that is what the affidavit requirement addresses. Finally, and most importantly, even were Ms. Hink's unduly labored reading of the statute a correct one, the record simply does not show her case was dismissed because her affidavit showed she could not obtain an opinion from a physician in the right specialty, or because the affidavit showed she obtained only a single expert opinion addressing some but not all her claims of liability or damages. Rather, the record reveals she failed to file any affidavit at all. While Ms. Hink says this was because she feared her affidavit would be rejected if filed, this Court can act only based on the record before it, not based on hypothetical facts not supported by the record. Harris v. Consol. Sch. Dist. No. 8 C, Dunklin Cty., 328 S.W.2d 646 , 654 (Mo. banc 1959) (An advisory decree upon hypothetical facts is improper.). Further, Generally, only those adversely affected by a statute have standing to challenge the constitutionality of the statute. Brehm, 426 S.W.3d at 5 . 5 Ms. Hink is not affected by the alleged deficits in the statute she argues exist, and this Court, therefore, declines to further discuss the merits of her hypothetical constitutional arguments.