Opinion ID: 2500868
Heading Depth: 3
Heading Rank: 1

Heading: Medical Record Matter

Text: Respondent was retained to represent a client who was injured in an automobile accident that occurred on May 3, 1995, in Hartsville, South Carolina. Medical records indicate the client received injuries to her head, neck, and right knee. Six days after the accident, the client sought follow-up care for headaches and knee pain. The medical record from this follow-up visit made no mention of any complaint concerning the client's heart, and instead noted that the heart has regular rate and rhythm w/o gallops or murmurs. Approximately one year later, the client began to experience chest discomfort while working out at the YMCA. Then, while at work on July 31, 1996, the client experienced recurrent chest discomfort and was taken to the Byerly Hospital where she was diagnosed as having had a myocardial infarction. Subsequently, she underwent treatment at Providence Hospital for that condition. In a medical record dated July 31, 1996, the client's condition was described as a history of recent exertional chest discomfort that had been ongoing for the last two months. The record also states that the client was [n]egative for a prior history of heart problems, and concludes that the client had suffered an [a]cute inferior posterior myocardial infarction. In 1998, Respondent filed a lawsuit on behalf of the client against the at-fault driver in the 1995 automobile accident. On April 27, 1998, Respondent sent a document, which appeared to be a medical record, [2] as part of the settlement package to the insurance company (Unisun) for the at-fault driver. Subsequently, Unisun's claims representative provided Respondent's case documents to Andrew McLeod, an attorney retained by Unisun. McLeod testified that he settled the case for the $15,000 policy limit, but clarified that he did not participate in the negotiations and primarily drafted the Covenant Not to Execute. He did, however, believe the document was part of the client's medical records. In March 2000, Respondent filed an amended lawsuit for underinsured motorist coverage. Lawrence Orr, the attorney who represented the insurance company (Horace Mann) in the underinsured motorist coverage claim, received Respondent's case documents from McLeod. This package, as well as Respondent's discovery, included the document that attributed client's heart problems to the 1995 automobile accident. Orr discovered that the document was not included in the medical records he independently subpoenaed from the client's medical providers. Months after settling the case, Orr reported the matter to the ODC by letter dated March 7, 2005. On March 24, 2005, Larry Huffstetler, Special Investigator for the South Carolina State Attorney General's Office, received the purported medical document. That same day, Respondent came to the ODC's office to deliver documents pursuant to a subpoena in another disciplinary matter. Upon his arrival, Respondent was taken to a conference room and questioned by Investigator Huffstetler and Assistant Deputy Attorney General Robert Bogan about the document. Respondent denied that he had manufactured or created any medical record and offered no explanation concerning the source of the suspected false medical record. Based on this matter, this Court placed Respondent on Interim Suspension beginning September 27, 2005. During the subsequent investigation and at the panel hearing on the formal charges, Respondent admitted he had directed an assistant to create the document. Although Respondent acknowledged the document had the appearance of a medical record, he denied producing it to Unisun or Orr as evidence of a medical record. Instead, Respondent claimed that his purpose for creating and producing the document was only to communicate his theory of the case during settlement negotiations, which was that any settlement for the 1995 automobile accident should include expenses for treatment of the client's heart condition. Respondent further explained that he had attached a sticky note to the document to apprise Orr that this document was not a medical record, but rather, his version of the damages. Orr testified there was no such note attached to the documents that he received.