Opinion ID: 852280
Heading Depth: 1
Heading Rank: 2

Heading: Exclusion of Defendant's Evidence Challenging Plaintiff's Medical Treatment

Text: The defendant contends that the trial court erred in striking portions of the videotape deposition of the defendant's medical expert, Paul Kern, M.D. Urging that he should have been permitted to present this evidence challenging the medical necessity of Dr. Saquib's nerve conduction studies at Priority 1 Medical and passive care treatment provided more than four weeks after the collision, first from Priority 1 Medical and later from Dr. Sheppard at Castleton Chiropractic, the defendant argues that he was thereby precluded from rebutting the plaintiff's claim. The defendant emphasizes that a party seeking to recover damages for medical expenses must prove that the expenses were both reasonable and necessary, citing Cook v. Whitsell-Sherman, 796 N.E.2d 271, 277 (Ind.2003), and Burge v. Teter, 808 N.E.2d 124, 132 (Ind.Ct.App.2004), trans. not sought. The plaintiff asserts that the testimony was properly excluded because it was contrary to Whitaker v. Kruse, 495 N.E.2d 223 (Ind.Ct.App.1986), trans. not sought, which she contends prevents a defendant tortfeasor from seeking to reduce his liability by questioning the judgment of a plaintiff's health care providers. Applying Whitaker, the Court of Appeals affirmed the trial court's decision to exclude portions of the defendant's medical witness's testimony, concluding that the defendant should not be able to challenge the particular course of treatment chosen by the plaintiff's medical care providers to treat the injuries resulting from the defendant's negligence. Sibbing, 901 N.E.2d at 1162. The defendant argues that if Whitaker is correct and applicable here, then a defendant will never be able to refute a plaintiff's claim that medical bills were reasonable and necessary. Appellant's Br. at 26. On appeal, the defendant contends that the trial court's striking of portions of Dr. Kern's deposition testimony erroneously prevented the defendant from challenging the reasonableness and the necessity of some of Cave's treatment. Appellant's Br. at 22. In other places, he identifies his claim by referring only to whether the challenged treatment was medically necessary. Id. at 13, Appellant's Reply Br. at 14. The defendant does not challenge the reasonableness as to any of the dollar amounts incurred by the plaintiff for her medical care, but rather he asserts that he should have been permitted to present evidence to challenge the necessity of certain treatment, specifically the nerve conduction study and passive care treatment provided more than four weeks after the collision. For over a century, some Indiana appellate opinions have recited that to recover damages for medical expenses, such expenses must be reasonable and necessary. See, e.g. Hickey v. Shoemaker, 132 Ind.App. 136, 143, 167 N.E.2d 487, 490 (1960), trans. not sought; City of Bedford v. Woody, 23 Ind.App. 401, 403, 55 N.E. 499, 500 (1899), trans. not sought. When this phrase has appeared, the issue usually addressed is the reasonableness of medical expenses, not the necessity of the medical treatment. For example, in Stanley v. Walker, 906 N.E.2d 852, 855 (Ind.2009), this Court recently observed that an injured plaintiff is entitled to recover damages for medical expenses that were both necessary and reasonable. Id. at 855. But our decision in Stanley concerned only the reasonableness of the amount of claimed medical expenses, not the necessity of the medical treatment. The principal issue was the admissibility of a defendant's evidence of discounted amounts accepted by the plaintiff's medical providers, and we conclude: The focus is on the reasonable value, not the actual charge. This is especially true given the current state of health care pricing. Id. at 856-57. Similarly, in Cook, 796 N.E.2d 271, we recite the reasonable and necessary qualification, id. at 277, but focus only on the reasonable component, holding that Indiana Evidence Rule 413 (which permits statements of charges for health care expenses to be admissible and to constitute prima facie evidence that the charges are reasonable) applies only to expenses already incurred, not to the estimated cost of future medical treatment. Id. at 278. Another example of our referring to the reasonable and necessary rule without explication or application is Smith v. Syd's, Inc., 598 N.E.2d 1065 (Ind. 1992), in which we recite the rule, it must be proven at trial that these expenses were both reasonable and necessary, id. at 1066, but find the issue waived. Id. at 1066-67. As authority for the reasonable and necessary requirement, Stanley rests upon Cook, Cook rests upon Smith, and Smith cites to Hickey and Bedford as its authority. While both Hickey and Bedford use the phrase reasonable and necessary, neither case addresses the necessary component. In Hickey, the issue addressed was whether the defendant could be liable for the wife's medical bills, then the debt of her husband. The issue in Bedford was the need to prove reasonable value of unpaid medical services. [4] In a few Indiana appellate cases, the outcomes appear to have involved application of the necessary component, although without detailed discussion. See, e.g. Childress, 779 N.E.2d 546 (applying damages directly attributable to the wrong to satisfy reasonable costs of necessary medical treatment, affirmed trial court order that jury verdict was inadequate); Cooper v. High, 262 Ind. 405, 407, 317 N.E.2d 177, 179 (1974) (finding that a rule disallowing recovery of a plaintiff's expenses for a physician incurred in litigation preparation was in accord with the Indiana policy of allowing the necessary and reasonable expenses for medical attention, medicine and nursing); Pennsylvania Co. v. Marion, 104 Ind. 239, 244, 3 N.E. 874, 877 (1885) (voluntary nursing services provided without charge were necessary to ameliorate the condition and suffering of the plaintiff and evidence of attending physician as to the value of these services was admissible). While the foregoing opinions provide little clarification as to the proper application of necessary, it is apparent that the shorthand phrase reasonable and necessary embodies two aspects. First, the claimed amount of medical expenses must be reasonable. Second, the nature and extent of the claimed medical treatment must be necessary. In the present case, the plaintiff asserts that evidence proffered by the defendant to challenge the medical necessity of some of the plaintiff's treatment was correctly excluded pursuant to Whitaker. In Whitaker, the Court of Appeals reversed a verdict for the defendants because an instruction improperly permitted the defendants to contest the propriety of the plaintiff's doctor's diagnosis and treatment. It concluded: We hold that an injured party may recover for injuries caused by the original tort-feasor's negligent conduct and for any aggravation of those injuries caused by a physician's improper diagnosis and unnecessary treatment or proper diagnosis and negligent treatment. In order to recover under this rule, the plaintiff need only show he exercised reasonable care in choosing the physician. Whitaker, 495 N.E.2d at 226. The court found that the defendants' allegation was merely that their expert witnesses would have elected to continue conservative treatments rather than perform surgery. Id. at 227. [5] The rationale expressed in Whitaker was that the tort-feasor created the necessity for medical care in the first instance. So long as the individual seeking medical care makes a reasonable choice of physicians, he is entitled to recover for all damages resulting from any aggravation of his original injury caused by a physician's misdiagnosis or mistreatment. Id. at 225-26, citing Suelzer v. Carpenter, 183 Ind. 23, 32, 107 N.E. 467, 470-71 (1915). The court also noted the Restatement (Second) of Torts § 457 (1965): If the negligent actor is liable for another's bodily injury, he is also subject to liability for any additional bodily harm resulting from normal efforts of third persons in rendering aid which the other's injury reasonably requires, irrespective of whether such acts are done in a proper or a negligent manner. Whitaker explained: Liability is imposed because it is reasonably foreseeable that medical care providers are human and capable of making mistakes. 495 N.E.2d at 226. Recognizing the general rule in Indiana that a plaintiff's recovery may be reduced if he fails to obey his physician's instructions and thereby exacerbates or aggravates his injury, the Whitaker court sternly rejected the proposition that an injured party could not recover for injuries caused by misdiagnosis or performance of an arguably unnecessary procedure, declaring that such a rule would place the injured party in the unenviable position of second-guessing his physicians in order to determine whether the doctor properly diagnosed the injury and chose the correct treatment. This court will not place innocent parties who have been injured by another's negligence in such a position. Id. But we do not read Whitaker to allow an injured plaintiff to recover for medical treatment wholly unrelated to a defendant's wrongful conduct. Whitaker does not eliminate the causation element. It specifically states: We hold that an injured party may recover for injuries caused by the original tort-feasor's negligent conduct.... Id. (emphasis added). And although holding that a plaintiff may recover for damages from a physician's misdiagnosis or mistreatment, the language of Whitaker is that such damages must be  resulting from any aggravation of his original injury caused by a physician's misdiagnosis or mistreatment. Id. (emphasis added). Under standard negligence doctrine, in order for a defendant to be liable for a plaintiff's injury, the defendant's act or omission must be deemed to be a proximate cause of that injury. City of Gary v. Smith & Wesson Corp., 801 N.E.2d 1222, 1243 (Ind.2003). `Proximate cause' has two components: causation-in-fact and scope of liability. Kovach v. Caligor Midwest, 913 N.E.2d 193, 197 (Ind.2009). The scope of liability doctrine asks whether the injury was a natural and probable consequence of the defendant's conduct, which in the light of the circumstances should have been foreseen or anticipated. Id. at 198. The analysis in Whitaker is helpful in understanding the contours of this foreseeability aspect when a defendant seeks to challenge the nature and extent of medical treatment selected and provided by a plaintiff's medical care professionals. Even if their medical judgment is unsound or erroneous, such human frailties are reasonably foreseeable and do not allow a defendant to escape liability for wrongful conduct. Id. at 226. This formulation does not have the result, as the defendant here warns, that a defendant will never be able to refute a plaintiff's claim that medical bills were reasonable and necessary. Appellant's Br. at 26. As to reasonableness, the Whitaker rule does not affect the evaluation of whether the amount claimed for a medical expense is reasonable. The rule does, however, guide application of the scope of liability aspect of the proximate cause element. While Whitaker restricts a defendant's evidence as to the scope of liability component of proximate cause, it does not preclude challenge to the causation-in-fact component. A future defendant may thus present evidence to counter a plaintiff's claim that but for the defendant's alleged negligence, the disputed medical treatment would not have occurred. See Kovach, 913 N.E.2d at 198; City of Gary, 801 N.E.2d at 1244. Thus, for example, a plaintiff may not recover damages for dental care received following a collision in which harm to the plaintiff's teeth was not implicated. Likewise, a defendant may properly challenge whether a plaintiff's medical treatment was not at all necessitated by the alleged tortious conduct but by a non-aggravated, pre-existing condition. In summary, we hold that the phrase reasonable and necessary, as a qualification for the damages recoverable by an injured party, means (1) that the amount of medical expense claimed must be reasonable, (2) that the nature and extent of the treatment claimed must be necessary in the sense that it proximately resulted from the wrongful conduct of another, and (3) the rule in Whitaker is a correct application of the scope of liability component of proximate cause. [6] In the present case, the defendant challenges the exclusion of evidence from his medical expert challenging the medical necessity of Dr. Saquib's nerve conduction studies at Priority 1 Medical and the passive care treatment provided more than four weeks after the collision, first from Priority 1 Medical and later under Dr. Sheppard at Castleton Chiropractic. The defendant does not assert that such treatment lacks causation in fact, that is, that plaintiff failed to establish that, but for the collision, the challenged treatment would not have occurred. Instead, the defendant disputes the medical judgment of the plaintiff's medical providers in choosing to administer the questioned studies and treatment. This he may not do. The trial court was correct to exclude the proffered evidence, and the Court of Appeals properly applied Whitaker to affirm the trial court's decision.