Court Opinion

ID: 6334094
Source: CourtListenerOpinion
Date Created: 2022-04-22 14:03:55.537632+00
Date Added: 2024-06-11T09:23:33.934123
License: Public Domain

IN THE SUPREME COURT OF IOWA

                                   No. 20–1124

               Submitted March 24, 2022—Filed April 22, 2022

ELIZABETH DOWNING and MARCELLA BERRY, as Co-Administrators of the
ESTATE OF LINDA BERRY,

      Appellants,

vs.

PAUL GROSSMANN, and CATHOLIC HEALTH INITIATIVES IOWA, CORP.
d/b/a MERCY MEDICAL CENTER, MERCY MEDICAL CENTER WEST
LAKES, and MERCY SURGICAL AFFILIATES,

      Appellees.

      On review from the Iowa Court of Appeals.

      Appeal from the Iowa District Court for Polk County, David Porter, Judge.

      The defendants seek further review of a court of appeals decision reversing

the district court’s grant of summary judgment in a medical malpractice action.

DECISION     OF     COURT    OF    APPEALS     VACATED;       DISTRICT     COURT

JUDGMENT AFFIRMED.

      Oxley, J., delivered the opinion of the court, in which all justices joined.
                                      2

      Steve Hamilton (argued) and Molly M. Hamilton of Hamilton Law Firm,

P.C., Clive, for appellants.

      Joseph F. Moser (argued) and Stacie M. Codr of The Finley Law Firm, P.C.,

Des Moines, for appellees.
                                               3

OXLEY, Justice.

       A benign cyst on Linda Berry’s right kidney was first detected on a

computerized tomography (CT) scan taken at Mercy Medical Center1 in 2004.

Ms. Berry visited Mercy over the next several years for a variety of reasons, and

the cyst was noted as an incidental finding on subsequent CT scans, including

one taken during a visit to the ER on October 1, 2009, when Dr. Paul Grossmann

treated her for colitis. This time, a radiologist noted the mass had grown in size

from the prior scans, suggesting the mass should be further evaluated. But,

according to the plaintiffs, no one mentioned the growing cyst to Ms. Berry or

her primary care physician until another CT scan was taken when she broke her

shoulder seven years later. By then it was too late. Ms. Berry was treated for

renal cancer in April 2016, the cancer metastasized to her bones, and she passed

away from cancer in 2019.

       Prior to her death, in 2018 Ms. Berry filed a medical malpractice action

against Dr. Grossmann and the Mercy affiliates for failing to disclose the kidney

mass in October 2009. But she ran up against Iowa’s six-year statute of repose

found in Iowa Code section 614.1(9) (2018), which barred her claims because

she initiated her case more than six years after Dr. Grossmann’s actions. Ms.

Berry’s estate asserts the defendants should be equitably estopped from raising

the statutory bar under the doctrine of fraudulent concealment. Fraudulent

       1Defendant   Catholic Health Initiatives Iowa, Corp. operates hospital facilities known as
Mercy Medical Center, Mercy Medical Center–West Lakes, and Mercy Surgical Affiliates. We refer
to these entities collectively as “Mercy.” Dr. Grossmann is an emergency room doctor affiliated
with the Mercy entities. The claims against the Mercy entities are all derivative of the claims
against Dr. Grossmann, and we consider the claims collectively against the defendants.
                                         4

concealment requires just that—fraudulent, or intentional, concealment of the

plaintiff’s cause of action. And the concealment must be distinct from the

underlying act being concealed. Otherwise, there would never be a time limit for

failure-to-disclose-type claims. When the underlying cause of action is one for

failure to disclose a medical condition, as here, a defendant’s continued failure

to disclose the condition that goes to the heart of the plaintiff’s underlying claim

does not meet the requirement for an independent and subsequent act of

concealment to trigger equitable estoppel.

      The court of appeals read the requirement for an independent act of

concealment too narrowly. The acts of concealment claimed by the estate are the

same acts by Dr. Grossmann that form the basis of the estate’s underlying claims

of negligence. The fraudulent concealment doctrine therefore does not apply, and

the defendants are not estopped from asserting the statute of repose defense,

which undisputedly applies to the facts of this case. For the reasons explained

below, we reverse the court of appeals and affirm the district court’s grant of

summary judgment for the defendants.

                                             I.

      We recite the facts supported by the record in the light most favorable to

the plaintiffs in considering whether the defendants were entitled to summary

judgment on their statute of repose defense. Berry’s primary care physician was

with Broadlawns Family Medicine, and she used Mercy for emergency care. In

2004, Berry was hospitalized at Mercy for abdominal pain, and a CT scan showed

a mass on her right kidney that was determined to be a benign cyst. Berry
                                         5

received another CT scan at Mercy in December 2006 when she was seen for a

urinary tract infection. This CT scan indicated her “right kidney is unchanged

with a stable right renal cyst.” Berry was not informed of the mass on her right

kidney at either visit.

      On October 1, 2009, Berry went to the Mercy emergency room complaining

of constipation and nausea. Dr. Paul Grossmann, the on-call emergency room

doctor, ordered a CT scan based on concerns Berry might have acute

appendicitis, diverticulitis, or an incarcerated hernia. The initial CT scan reading

revealed no abnormalities other than constipation, and Berry was sent home

with medication for constipation. However, a final reading of the CT scan

revealed that Berry had mild sigmoid colitis. Dr. Matthew Severidt, a Mercy

resident working with Dr. Grossmann, called Berry’s daughter, Elizabeth

Downing, as they were driving home and told her, “You need to bring your mom

back. Not everything was okay on the CT scan. Come back.” Berry was prescribed

an antibiotic for the colitis and again discharged with an appointment to follow

up with Dr. Grossmann about the colitis on October 6.

      The final reading of the CT scan also showed a large exophytic mass on

Berry’s right kidney that had increased in size from the scans taken in 2004 and

2006. Dr. Severidt wrote an addendum to Berry’s chart noting the mass and

stating: “Suggest MRI for evaluate.” He also noted, “Patient will follow up with

Dr. Grossmann in one week at which time further evaluation of right kidney can

be undertaken.” Although Dr. Severidt noted, “This was discussed with patient

who voiced understanding,” nothing was mentioned about the mass in Berry’s
                                        6

discharge papers, and Berry and Downing both denied ever being told about the

mass despite the unusual request to return to the hospital because “not

everything was ok” with the CT scan. We assume the mass was not discussed

with Berry for purposes of reviewing the summary judgment ruling.

      Berry went back to Mercy’s emergency room late on October 3 with

complaints of increased abdominal pain and constipation. Another CT scan

showed the colitis was responding to the antibiotics, again depicting the mass

on Berry’s right kidney. Although the mass was deemed not to be the cause of

Berry’s pain, Dr. Roe, one of Dr. Grossmann’s partners who was on call that

night, wrote in his consultation notes: “Plan: Recommended follow up for R.

kidney cystic mass with Dr. Grossmann, already discussed with patient on

10/1/09.” A copy of the October 3 CT scan results in Berry’s patient chart

contained Dr. Grossmann’s signature, indicating his acknowledgment of the

results and recommendations for further testing. But again, Berry was not

informed of the right kidney mass seen on the CT scan and was not informed

that further testing was recommended.

      On October 6, Berry saw Dr. Grossmann for her follow-up appointment

concerning the colitis. Dr. Grossmann examined Berry and scheduled a

colonoscopy. Dr. Grossmann’s dictated notes made no mention of consulting

with Berry about the kidney mass. Dr. Grossmann dictated and sent a letter to

Berry’s primary care physician at Broadlawns regarding his diagnosis and

treatment of Berry’s colitis. At his deposition, Dr. Grossmann explained that the

letter was intended to inform Berry’s primary care physician about the treatment
                                        7

he provided. Dr. Grossmann claims he told Berry about the kidney mass at the

October 6 appointment but he did not document it in his notes or the letter to

her primary care physician because he was not consulted to treat the mass and

it was a urology issue that was outside the scope of the treatment he could

provide. Downing accompanied Berry to the October 6 appointment, and both

she and Berry testified Dr. Grossmann never mentioned the mass, a fact we

again accept as true. The estate’s expert opines that Dr. Grossmann violated the

standard of care because even incidental findings on a CT scan should be

reported to a patient’s primary care physician for follow-up.

      After the colonoscopy and further evaluation of the colitis treatment,

Dr. Grossmann discharged Berry from his care in December, informing her that

her conditions had resolved. At an April 15, 2010 appointment, Berry’s primary

care physician read Dr. Grossmann’s October 6 letter to Berry, which did not

mention the right kidney mass or recommend further testing. Despite the notes

in Berry’s chart about the kidney mass, no additional testing was conducted.

      Fast forward six years to April 24, 2016. Berry fell, severely injuring her

shoulder and sending her back to Mercy’s emergency room. Given Berry’s bone

abnormalities and her medical history, the ER doctor, Dr. Todd Peterson,

recommended to Berry’s primary care physician that Berry follow up with an

orthopedic surgeon at the University of Iowa Hospitals and Clinics. As relevant

here, a CT scan of Berry’s chest, abdomen, and pelvis taken at the University

Hospitals revealed that the right kidney mass had grown to 4.4 cm and was

concerning for cystic renal cell neoplasm. Again, Berry was not informed of the
                                         8

mass during her treatment, but a nurse discharging Berry happened to mention

the kidney mass to her. Berry claims this was the first time anyone ever informed

her of the mass on her kidney.

        On April 29, Berry was diagnosed with metastatic renal cell carcinoma

through a CT biopsy at the University Hospitals. In November 2016, Berry

underwent a partial right nephrectomy to treat her renal cancer. Although the

surgery was initially successful, a spinal tumor was discovered in July 2017.

Berry underwent surgery, chemotherapy, and radiation treatment. Berry passed

away on May 22, 2019, from renal cell carcinoma with metastasis to the bone.

        Prior to her death, Berry sued Dr. Grossmann, Mercy Surgical Affiliates,

and Catholic Health Initiatives Iowa, Corp. d/b/a Mercy Medical Center on April

10, 2018. She asserted medical malpractice claims related to Dr. Grossmann’s

alleged failure to disclose information about the kidney abnormalities revealed

on the CT scans to Berry or her primary care physician, preventing Berry from

seeking further testing and care. Her expert opined that even though the kidney

mass was an incidental finding to Berry’s treatment for colitis, the standard of

care required Dr. Grossmann to inform Berry of the mass as well as follow up

directly with Berry’s primary care physician, neither of which was documented

in Dr. Grossmann’s notes. Berry alleged that having ordered the CT scans,

Dr. Grossmann was responsible for all findings, including findings incidental to

his treatment. Berry also alleged that Dr. Grossmann’s failure to inform her

about     the   nature   of   her   medical   issues   amounted   to   fraudulent
                                        9

misrepresentations. Following Berry’s death in May 2019, her daughters, as

coadministrators of her estate, were substituted as plaintiffs.

      The defendants moved for summary judgment on the basis that the claims

were precluded by the six-year statute of repose for medical malpractice claims.

See Iowa Code § 614.1(9)(a). The estate argued that Dr. Grossmann’s actions

amounted to fraudulent concealment, such that the defendants should be

estopped from raising the statute of repose defense. The district court granted

the defendants’ motion on July 17, 2020, rejecting the plaintiffs’ reliance on

fraudulent concealment to avoid the six-year bar to its claims. The estate

appealed, and we transferred the case to the court of appeals. The court of

appeals reversed the district court’s grant of summary judgment, holding there

was a genuine issue of material fact concerning whether Dr. Grossmann’s

fraudulent concealment precluded the medical professionals’ statute of repose

defense. We granted the defendants’ application for further review.

                                            II.

      We review a district court’s grant of summary judgment for correction of

errors of law. Skadburg v. Gately, 911 N.W.2d 786, 791 (Iowa 2018). Summary

judgment is proper if the record shows that there is no genuine issue as to any

material fact and that the moving party is entitled to judgment as a matter of

law. Christy v. Miulli, 692 N.W.2d 694, 699 (Iowa 2005). The moving party must

show an absence of a genuine issue of material fact. Skadburg, 911 N.W.2d at

791. We view the facts in the record in the light most favorable to the nonmoving

party, and we draw every legitimate inference in their favor. Id.
                                        10

                                             III.

      The defendants contend that the court of appeals decision effectively

eliminated application of the statute of repose in any failure to disclose case

where subsequent treatment by the same providers exists. The defendants ask

us to uphold the district court’s order, contending that this case is barred by the

statute of repose because it was filed nearly nine years after the care in question.

Berry’s estate argues that the court of appeals correctly held that a jury could

conclude from the evidence that Dr. Grossmann was guilty of concealing Berry’s

kidney cyst, which would estop the defendants from raising the statute of repose

defense. Resolution of this case turns on a proper application of the fraudulent

concealment doctrine.

      This case involves the application of a statute of repose, to be distinguished

from a statute of limitations. A statute of limitations governs how much time a

plaintiff has to bring a cause of action after it accrues. An action accrues when

the plaintiff is injured, or in some cases, when she discovers or reasonably

should have discovered she has been injured. Conversely, a statute of repose

governs how long a potential defendant is subject to liability for his actions. So

a statute of repose runs from the time of the defendant’s action, regardless of

when the injury is incurred or discovered, and may cut off a cause of action

before it has accrued or even before there has been an injury. See, e.g., Bob

McKiness Excavating & Grading, Inc. v. Morton Bldgs., Inc., 507 N.W.2d 405, 408–

09 (Iowa 1993) (holding that the fifteen-year statute of repose in section

614.1(11) related to improvements to real property precluded an action against
                                        11

an architect for negligently designing a building constructed in 1971 that

collapsed in 1991 even though there was no injury, and therefore no legal cause

of action, until the building’s collapse); see also Albrecht v. Gen. Motors Corp.,

648 N.W.2d 87, 91–94 (Iowa 2002) (holding that the fifteen-year statute of repose

in section 614.1(2A) precluded products liability claims against General Motors

premised on a defective seat belt that contributed to a minor’s injuries in a car

accident brought more than fifteen years after the car was purchased).

      Iowa Code section 614.1(9) contains both a statute of limitations and a

statute of repose for medical malpractice claims. A plaintiff can bring a medical

malpractice action within two years from the time she knows, or through

reasonable diligence should know, of the injury or death for which she claims

damages. Iowa Code § 614.1(9)(a). This is a statute of limitations, measured from

the accrual of the plaintiff’s cause of action. If this was the only statutory

limitation, Berry’s claims would arguably have been timely since she filed this

lawsuit within two years of being told about the mass on her kidney.

      But section 614.1(9)(a) goes on to provide: “in no event shall any action be

brought more than six years after the date on which occurred the act or omission

or occurrence alleged in the action to have been the cause of the injury or death,”

with an exception not relevant here. Iowa Code § 614.1(9)(a). This is a statute of

repose, measured from the time of the defendant’s actions. See Est. of Anderson

v. Iowa Dermatology Clinic, PLC, 819 N.W.2d 408, 414 (Iowa 2012) (“Unlike the

statute of limitations, under which a claim accrues for injuries caused by medical

negligence when the plaintiff knew, or through the use of reasonable diligence
                                        12

should have known, of the injury, a statute of repose runs from the occurrence

of the act causing the injury.”). The six-year bar provides “an outside limitation

for all lawsuits, even though the injury had not been discovered.” Rathje v. Mercy

Hosp., 745 N.W.2d 443, 455 (Iowa 2008). While the statute of repose can have

harsh consequences by cutting off a cause of action before it is discovered or

even arises, it “reflect[s] the legislative conclusion that a point in time arrives

beyond which a potential defendant should be immune from liability for past

conduct.” Est. of Anderson, 819 N.W.2d at 419 (quoting Albrecht, 648 N.W.2d at

91); see also Schlote v. Dawson, 676 N.W.2d 187, 194 (Iowa 2004) (recognizing

the statute “severely restricts the rights of unsuspecting patients who may be

injured because of unnecessary and excessive surgery” but “it is up to the

legislature and not this court to address this problem”); Albrecht, 648 N.W.2d at

94 (“When a period of repose expires and bars a claim before it accrues (as

occurred here), there is nothing a potential claimant—adult or minor—can do to

avoid the bar.”).

      The statute of repose is an affirmative defense to a malpractice claim. And

despite its rigid bar, certain equitable principles may prevent, or estop, a

defendant from raising the defense. One such equitable doctrine, fraudulent

concealment, arises “when by his own fraud [the defendant] has prevented the

other party from seeking redress within” the applicable statutory period. Est. of

Anderson, 819 N.W.2d at 414 (quoting Christy, 692 N.W.2d at 702) (noting that

the doctrine of fraudulent concealment has been part of our jurisprudence for

over a century and survived codification of the statute of repose in section
                                         13

614.1(9)). Fraudulent concealment “is a form of equitable estoppel that . . . allows

a plaintiff to pursue a claim that would be otherwise time barred under the

statute of repose.” Id. As we explained in Christy v. Miulli, “equitable estoppel has

nothing to do with the running of the limitations period or the discovery rule; it

simply precludes a defendant from asserting the statute as a defense when it

would be inequitable to permit the defendant to do so.” 692 N.W.2d at 701.

      A plaintiff seeking to estop a defendant from raising a statute of repose

defense must prove four things: “(1) The defendant has made a false

representation or has concealed material facts; (2) the plaintiff lacks knowledge

of the true facts; (3) the defendant intended the plaintiff to act upon such

representations; and (4) the plaintiff did in fact rely upon such representations

to his prejudice.” Id. at 702 (quoting Meier v. Alfa–Laval, Inc., 454 N.W.2d 576,

578–79 (Iowa 1990)). The party alleging fraudulent concealment has the heavy

burden to prove each of the elements by “a clear and convincing preponderance

of the evidence.” Id.

      Equitable estoppel is not premised on the fact that the defendant has

harmed the plaintiff but on the fact that—having harmed the plaintiff—the

defendant also concealed the existence of a cause of action. Recognizing this

distinction, fundamental “to the first element, a party relying on the doctrine of

fraudulent concealment must prove the defendant did some affirmative act to

conceal the plaintiff’s cause of action independent of and subsequent to the

liability-producing conduct.” Id. The existence of a fiduciary duty, such as that

between a physician and his patient, “relaxes the requirement of affirmative
                                       14

concealment,” Est. of Anderson, 819 N.W.2d at 415 (emphasis added), such that

silence can supply the concealment, but “the act of concealment must [still] be

independent of and subsequent to the original wrongdoing establishing liability.”

Skadburg, 911 N.W.2d at 798.

      A review of our cases demonstrates the distinction between an underlying

liability-producing act and a subsequent, independent act of concealment. In

Christy, a doctor who caused a brain bleed during a biopsy procedure reported

in the patient’s medical records that the procedure was performed without

complications and told the patient’s spouse the bleed occurred away from the

biopsy site, suggesting it was caused by an unrelated infection. 692 N.W.2d at

698–99. The acts of concealment—misleading the wife about the location of the

bleed relative to the biopsy and recording the procedure was completed without

complications in the medical records—were independent and subsequent to the

liability-creating act of negligently performing the biopsy. Id. at 700–04. In

Skadburg v. Gately, an attorney erroneously told his client, who was the

administrator of her mother’s estate, to use proceeds from life insurance and

401(k) accounts to pay the estate’s debts even though those assets were exempt

and the estate’s debts exceeded its assets. 911 N.W.2d at 790. The attorney’s

silence in response to the client’s later communications lamenting that she had

used exempt assets to pay the estate’s debts satisfied the requirement for an act

of concealment that was independent and subsequent to the underlying

negligence of improperly advising the client to use exempt assets to pay the

estate’s debts. Id. at 799–800.
                                         15

      On the other hand, where a physician unnecessarily removed a patient’s

voice box and failed to tell the patient that other less intrusive treatments were

available, we held that “failure to make those disclosures lies at the heart of the

Schlotes’ claims” so that the “failure was not an independent, subsequent act of

concealment.” Schlote, 676 N.W.2d at 195. In Van Overbeke v. Youberg, an

obstetrician failed to give RHoGAM to a pregnant patient who was RH negative

to prevent blood sensitization before delivering her baby. 540 N.W.2d 273, 274–

75 (Iowa 1995), abrogated on other grounds by Christy, 692 N.W.2d at 701–02.

In the patient’s subsequent medical malpractice action, we explained that where

“the doctor’s failure to disclose to the plaintiff that she needed the RHoGAM

injection lies at the heart of her claim,” the “[f]ailure to disclose that need, as a

ground of liability, cannot [also] be the basis for fraudulent concealment.” Id. at

276–77. “If it could be, there would effectively be no statute of limitations for

negligent failure to inform a patient.” Id. at 277. This reasoning follows from

cases addressing the application of fraudulent concealment to a fraud claim.

Absent “evidence of false or misleading conduct by [the defendant], other than

the alleged fraud itself, that dissuaded the [plaintiffs] from investigating a

possible claim or that caused them to refrain from filing suit,” fraudulent

concealment does not preclude a statute of limitations defense to a fraud claim.

Hallett Const. Co. v. Meister, 713 N.W.2d 225, 231–32 (Iowa 2006).

      This case follows the pattern of Schlote and Van Overbeke rather than

Christy and Skadburg. The liability-producing conduct was Dr. Grossmann’s

alleged failure to disclose to Berry the concerning findings on her CT scan and
                                       16

to inform her primary care physician about the recommendation for further

evaluation of the kidney mass. But the plaintiffs then rely on these same acts—

Dr. Grossmann’s failure to tell Berry about the mass when she returned to the

hospital on October 1 or saw him in his office on October 6 as well as

Dr. Grossmann’s October 6 letter to Berry’s primary care physician—as his acts

of concealment. The court of appeals concluded these separate opportunities to

disclose the kidney mass provided the necessary temporal separation between

the initial failure to disclose the Mercy radiologist’s October 1 recommendation

for further evaluation of the mass, and the later concealment by Dr. Grossmann

after gaining actual knowledge of the mass but concealing the information from

Berry in subsequent direct interactions. The court of appeals similarly

determined that Dr. Grossmann’s October 6 letter to Berry’s primary care

physician constituted a further act of concealment.

      The court of appeals’ focus on the temporal separation overlooks the

requirement that the concealment also be independent of the liability-producing

act. Fraudulent concealment comes into play when a defendant conceals a cause

of action against him. That Dr. Grossmann had multiple opportunities to

disclose the kidney mass just means he acted negligently on successive

occasions—a point made by Berry’s expert. This is not like Skadburg, where the

attorney first gave his client bad advice about paying the estate’s debts with

exempt assets and then stood silently by when she lamented the loss of funds

from the estate. See 911 N.W.2d at 799–800. The silence in Skadburg was

independent of the prior negligent advice. Rather, this is like Schlote v. Dawson,
                                        17

where “failure to make those disclosures lies at the heart of [Berry’s] claims; such

failure was not an independent, subsequent act of concealment.” 676 N.W.2d at

195; see also Van Overbeke, 540 N.W.2d at 276–77 (“Failure to disclose that

need, as a ground of liability, cannot [also] be the basis for fraudulent

concealment.”).

      Berry is essentially asserting a substantive claim of fraudulent

concealment premised on a duty by Dr. Grossmann to disclose the incidental

results of her CT scan. But she brought her claim more than six years after

Dr. Grossmann failed to make that disclosure. To allow her claim to go forward

would effectively eviscerate the statute of repose for claims of failure to inform a

patient. See Van Overbeke, 540 N.W.2d at 276–77. To avoid the statute of repose,

Berry must identify some act of concealment that is independent of the duty to

disclose the CT scan results. Unable to do so, Berry cannot rely on fraudulent

concealment to estop defendants from asserting the six-year statute of repose as

a defense to Berry’s claims.

      Berry brought her claims more than six years after the defendants’

conduct, and the claims are barred by the statute of repose. See Iowa Code

§ 614.1(9)(a). The district court properly granted summary judgment, and the

court of appeals erred in reversing.

                                             IV.

      For the foregoing reasons, we vacate the court of appeals decision and

affirm the district court’s grant of summary judgment in favor of the defendants.

      DECISION OF COURT OF APPEALS VACATED; DISTRICT COURT

JUDGMENT AFFIRMED.