Court Opinion

ID: 2964599
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Date Created: 2015-09-21 21:28:06.279401+00
Date Added: 2024-06-11T11:37:25.375301
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USCA1 Opinion

	

                            UNITED STATES COURT OF APPEALS
                                FOR THE FIRST CIRCUIT
                                 ____________________

          No. 96-1429

                               LINDA M. DANIELS-RECIO,

                                Plaintiff - Appellee,

                                          v.

                         HOSPITAL DEL MAESTRO, INC., ET AL.,

                               Defendants - Appellants.

                                 ____________________

          No. 96-1686

                               LINDA M. DANIELS-RECIO,

                                Plaintiff - Appellant,

                                          v.

                         HOSPITAL DEL MAESTRO, INC., ET AL.,

                               Defendants - Appellees.

                                 ____________________

                    APPEALS FROM THE UNITED STATES DISTRICT COURT

                           FOR THE DISTRICT OF PUERTO RICO

                 [Hon. Raymond L. Acosta, Senior U.S. District Judge]
                                          __________________________

                                 ____________________

                                        Before

                               Torruella, Chief Judge,
                                          ___________

                     Coffin and Campbell, Senior Circuit Judges.
                                          _____________________

                                _____________________

               Mario Pab n-Rosario, with  whom Jos  Luis  Gonz lez-Casta er
               ___________________             ____________________________
          and  Law Offices of Jos  Luis Gonz lez-Casta er were on brief for
               __________________________________________
          appellant SIMED.
               Kevin  G. Little, with whom  Law Offices David  Efr n was on
               ________________             ________________________
          brief for Linda Daniels-Recio.
               Edgardo A. Vega-L pez, with  whom Jim nez, Graffam & Lausell
               _____________________             __________________________
          was on  brief for  Asociaci n Hospital  del Maestro and  Evanston
          Insurance Company.

                                 ____________________

                                    March 28, 1997
                                 ____________________

                                         -2-

                    TORRUELLA,  Chief  Judge.    On June  24,  1992,  Linda
                    TORRUELLA,  Chief  Judge.
                                ____________

          Daniels-  Recio  ("Daniels")  filed a  medical  malpractice  suit

          against Dr. Rafael S nchez-Monserrat  ("S nchez") and  Asociaci n

          Hospital del  Maestro ("AHDM"),  a hospital  in San Juan,  Puerto

          Rico.   On November 2, 1992, Daniels amended her complaint to add

          Dr. S nchez'   insurer,  Sindicato   de   Aseguradores  Para   la

          Suscripci n  Conjunta de  Seguros de  Responsibilidad Profesional

          M dico  Hospitalaria  ("SIMED"),  and  AHDM's  insurer,  Evanston

          Insurance Company  ("Evanston"), as  defendants.  On  January 17,

          1995, AHDM and  Evanston filed a motion for summary judgment.  On

          March 30,  1995, the district  court granted AHDM  and Evanston's

          motion for summary judgment.

                    In  the meantime, on February  3, 1995, Daniels filed a

          motion  in  limine  seeking   determination  of  coverage   under

          Dr. S nchez' insurance  policy with SIMED.  On February 28, 1996,

          the district court determined that Daniels'  claim was covered by

          Dr.  S nchez' policy, which had a  stated limit of $500,000.  The

          case  was scheduled  for trial.   On March 15,  1996, following a

          settlement  conference, Daniels,  Dr.  S nchez and  SIMED entered

          into  a  Stipulation  Agreement  whereby  they  agreed  that  the

          district  court would  enter  final judgment  for Daniels  in the

          amount  of $500,000  in order  for SIMED  to appeal  the district

          court's determination of policy coverage.

                    We  have  before  us  SIMED's  appeal  from  the  final

          judgment,  based  on  the  district  court's allegedly  erroneous

          determination  regarding policy  coverage,  as well  as  Daniels'

                                         -3-

          appeal  from the  district court's entry  of summary  judgment in

          favor of AHDM and Evanston.  We affirm.

                                      BACKGROUND
                                      BACKGROUND

                    As our review  of the district court's grant of summary

          judgment is de novo, we present the background facts in the light
                      __ ____

          most   favorable  to   the  nonmovant,  drawing   all  reasonable

          inferences  in her  favor.   Dubois  v.  United States  Dep't  of
                                       ______      ________________________

          Agriculture, 102 F.3d 1273, 1283-84 (1st Cir. 1996).
          ___________

                    In May  1989, after being admitted  to AHDM's emergency

          room,  Daniels was referred by AHDM staff to Dr. Regis-Bonilla, a

          pneumologist at Cl nica Las Am ricas.  Daniels received treatment

          from Dr.  Regis-Bonilla for approximately nine  months, before he

          moved his practice to another city.  After Dr. Regis-Bonilla left

          his  San Juan practice,  Dr. S nchez joined  Cl nica Las Am ricas

          and began treating Daniels.  In early 1990, Dr. S nchez diagnosed

          Daniels' condition as "silent asthma."

                    On  August 31, 1990, Daniels was again admitted to AHDM

          on  an emergency basis.  She was hospitalized until September 17,

          1990.    During  this  hospitalization,  Dr.  S nchez  prescribed

          Medrol, an adrenocortical steroid, for  the first time.  Extended

          use of this medication  can cause a number of  adverse reactions,

          including  hypertension,  muscle   weakness,  steroid   myopathy,

          osteoporosis, spinal compression fractures, abdominal distention,

                                         -4-

          development of a Cushingoid  state,1 and manifestations of latent

          diabetes mellitus.

                    Daniels  was again  admitted  to AHDM  on an  emergency

          basis on October 5, 1990.  After a consultation, Dr. S nchez took

          over as  Daniels' primary attending physician.   Hospital records

          showed  that Daniels had been  taking Medrol since  her August 31

          admission  and that she had steroid myopathy as a complication of

          the steroid  treatment.   Daniels was discharged  on November  1,

          1990.

                    On December 17, 1990, Daniels yet again was admitted to

          AHDM.     Daniels  had   been  taking   Medrol  since   her  last

          hospitalization and  continued to  take it throughout  this stay.

          Steroid  complications,  specifically  steroid-induced  diabetes,

          were  noted in her records.   Daniels was  discharged on December

          31,  1990, with records showing that her "asthma" continued to be

          active and that she was taking Medrol upon her discharge.

                    On May 30,  1991, Daniels  was admitted to  AHDM for  a

          fifth  time.   She was  still taking  Medrol at  the time  of her

          admission and  was continued on the medication  during the course

          of her hospitalization.   Several steroid  related complications,

          including  Cushing's  syndrome, osteoporosis,  spinal compression

          fractures, hypertension, and  a decrease in height, were noted at

          the time of her admission.  She was discharged on June 28, 1991.

                              
          ____________________

          1  Cushing's Syndrome is characterized  by mood phases, excessive
          hair growth,  increased bruisability, peripheral  muscle atrophy,
          the  formation of  a pot  belly and the  formation of  a "buffalo
          hump" on the afflicted person's back.

                                         -5-

                    During  each hospitalization,  a series  of respiratory

          function  tests were  run  on  Daniels.    None  of  these  tests

          indicated that she was having respiratory difficulty.

                    Upon her last  discharge, on June 28, 1991, Daniels was

          referred  by  Dr.  S nchez  to  the  National Jewish  Center  for

          Immunology and Respiratory Medicine ("National Jewish Center") in

          Denver, Colorado.   Dr.  S nchez' referral letter  indicates that

          Daniels had been prescribed Medrol for the previous twelve months

          and that she was suffering from complications related to extended

          corticosteroid  usage.  On August 26, 1991, Daniels had her first

          appointment at National Jewish Center.  At the time of this first

          visit,  the  staff  at  National Jewish  Center  questioned  both

          Dr. S nchez' diagnosis of "silent  asthma" and his treatment with

          Medrol for  at least a year.  The staff at National Jewish Center

          tapered  Daniels'  Medrol dosage  and gave  her  a final  dose on

          September  3, 1991, the day  she was admitted  to National Jewish

          Center.    Doctors there  discovered  that  her osteoporosis  had

          developed  to such an extent that her bone mass was approximately

          70%  of the  normal  level.   The  National Jewish  Center  staff

          diagnosed  Daniels  as  suffering  from   breathing  difficulties

          secondary to  an anxiety disorder.   Daniels was  discharged from

          National Jewish Center on September 21, 1991.

                    Daniels'  experts  indicated  that  the   diagnosis  of

          "silent asthma"  was, at least ultimately, incorrect based on the

          objective respiratory test results.   They further stated  that a

          course  of  Medrol treatment  extending  beyond  two weeks  would

                                         -6-

          certainly  result  in  the severe  complications  experienced  by

          Daniels.

                                      DISCUSSION
                                      DISCUSSION

                    In  this   diversity   case,  we   apply  Puerto   Rico

          substantive law.   See Erie R.R. Co. v. Tompkins, 304 U.S. 64, 92
                             ___ _____________    ________

          (1938);  Carota v. Johns Manville  Corp., 893 F.2d  448, 450 (1st
                   ______    _____________________

          Cir. 1990).

          I.  Policy Coverage
          I.  Policy Coverage

                    SIMED  issued to  Dr. S nchez  a "claims  made" medical

          malpractice  insurance policy  effective  from July  7, 1991,  to

          July 7,  1992.   This policy  limited liability  to $500,000  per

          "medical incident"  that occurred during the  period of coverage,

          up to  an  aggregate  of  $1,000,000.   The  policy  also  had  a

          retroactive  component, which  provided coverage  to  Dr. S nchez

          from July  2, 1986 to July  7, 1991.  The  retroactive portion of

          the policy  provided coverage of $100,000  per "medical incident"

          that occurred during the retroactive period of coverage, up to an

          aggregate  of $300,000.    The question  presented  below and  on

          appeal is when Daniels'  "medical incident" occurred, which would

          determine which policy, and coverage limit, applied.

                    SIMED claims  the district  court erred by  determining

          that Daniels'  "medical incident" spanned the  coverage period of

          both policies2 and, thus,  that Daniels' claim is covered  by the
                              
          ____________________

          2  The policy language states:

               The  Syndicate will pay on behalf  of the Insured, with
               respect only to his practice within the Commonwealth of
               Puerto Rico:

                                         -7-

          subsequent policy, whose liability limit is $500,000.  We find no

          error in the district court's determination.

                    The  policy  language, including  the  language  of the

          amendment,  as set out in the margin, ties policy coverage to the

          timing of medical incidents.3  The district court properly framed

          the issue as follows:

                    if the incident transcended the period of the
                    lower  policy  coverage,   that  is,  if  Dr.
                    S NCHEZ MONSERRAT'S rendering of,  or failure
                    to  render   professional  services  extended
                    beyond the July 7, 1991 date, then the higher
                    coverage  would apply because all his acts or
                    omissions, when taken together,  comprise one
                              
          ____________________

               All  sums  which  the   Insured  shall  become  legally
               obligated to pay as damages because of injury  to which
               this policy applies caused by medical incident . . . .

          Medical incident is defined as:

               [A]ny  act or  omission  . .  .  in the  furnishing  of
               professional  medical .  . .  services by  the Insured.
               Any  such act  or omission,  together with  all related
               acts or omissions in the furnishing of such services to
               any  one  person   shall  be  considered   one  medical
               incident.

          The Retroactive  Date Amendment Endorsement II,  which deals with
          retroactive  insurance coverage  in  the amount  of $100,000  per
          medical incident, states:

               Irrespectively of the  retroactive date and  the limits
               of  liability shown  in  the Declarations  Page of  the
               above numbered  policy, in consideration of the payment
               of  the above stated  premium, claims arising  out of a
               medical incident which occurred  between 7-02-86 and 7-
               07-91 will be covered by this policy subject to a limit
               of liability  of $100,000  per medical incident  and an
               aggregate of $300,000.

          3  Because the  "event" triggering policy coverage is  the timing
          of the medical incident, SIMED's repeated references in its brief
          to  state and federal cases  that reviewed policies  in which the
          triggering event  was the  manifestation of the  injury miss  the
          mark.

                                         -8-

                    medical  incident  pursuant  to   the  policy
                    definitions.

          Amended Order  Granting Plaintiff's Motion in  Limine and Setting

          Trial and Pretrial Settlement Conference, Feb. 28, 1996, at 2-3.

                    Title 26, section  1114, of the Puerto  Rico Civil Code

          governs the  contents of insurance policies.   In accordance with

          this  provision,  language  in  an  insurance  policy  is  to  be

          construed according to the  "most common and usual meaning, . . .

          paying  . . .  attention .  . .  to the  general use  and popular

          meaning of the idioms."  Morales Garay v. Rold n Coss, 110 P.R.R.
                                   _____________    ___________

          909, 916 (1981).4 Moreover, "insurance contracts, being contracts

          of  adhesion, are  to  be liberally  construed  in favor  of  the

          insured."  Rivera  v. Insurance  Co. of Puerto  Rico, 103  P.R.R.
                     ______     ______________________________

          128,  131 (1974);  see also  P.R. Laws  Ann. tit.  26,    1114(2)
                             ________

          (Supp. 1996)  ("In the interpretation of said  policies, the text

          that is of most benefit to the insured shall prevail.").

                    The  district court  relied on  the following  facts in

          reaching its determination that the medical incident spanned both

          policies  and, therefore,  triggered coverage  of the  subsequent

          policy:

                       1.  Insurance Company Progressive Report

                      In the Progressive Report submitted  to the
                    Caribbean  American  Life Assurance  Company,
                    Dr. S NCHEZ   MONSERRAT    marked   the   box
                    indicating "YES" to the question posed on the
                    report  which asked  "Is patient  still under
                    your care for  this condition?".  He  further
                    informed that she had received a consultation
                    from his  office on  August 4, 1991  and that
                              
          ____________________

          4  Page cites are to the Official Translation.

                                         -9-

                    she  was   at  the   time  in   Colorado  for
                    "treatment."    Significantly, the  report is
                    dated September 3, 1991, and is filled out in
                    the doctor's own handwriting.

                             2.  Pulmonary Questionnaire

                      SIMED argues that the doctor's treatment of
                    Ms. DANIELS ended on  June 28, 1991, the date
                    of her  last hospitalization.   It  bases its
                    belief   on   the   Pulmonary   Questionnaire
                    prepared  by  Dr.   S NCHEZ  MONSERRAT,   for
                    submission to the Social  Security Disability
                    Determination Program.   This form was filled
                    out  by   the  doctor  on  April   20,  1992,
                    approximately   seven    months   after   the
                    aforementioned    insurance     report    was
                    completed.  Although  on this  questionnaire,
                    the doctor indicates that  "[Ms. Daniels was]
                    not  seen since  June 28,  1991",  it appears
                    that  the  doctor's  statements therein  were
                    made in  reference to  his last visit  to the
                    plaintiff   at  the   hospital.     A  closer
                    examination  of page 3  of the questionnaire,
                    requesting  a listing of the office visits by
                    the patient, reveals that the  last entry for
                    Ms. DANIELS  was for  May 30, 1991,  the date
                    that the doctor ordered  her hospitalization,
                    which hospitalization concluded  on June  28,
                    1991.     Thus,  noticeably   absent  is  the
                    August 4,  1991,  consultation  which he  had
                    disclosed in the form filled out seven months
                    earlier    for    the   insurance    company.
                    Furthermore, in  the aforementioned pulmonary
                    questionnaire,  the   doctor  indicated  that
                    Ms. DANIELS was "sent to the Jewish Institute
                    of Allergy &  Immunology--Aug. 26,  1991...."
                    Since  he  was  the  doctor  originating  the
                    referral to the  Institute, this  affirmation
                    could be construed as  another acknowledgment
                    that Ms. DANIELS was still under his care and
                    treatment  at that time;  clearly beyond July
                    7, 1991, the higher coverage date.

                          3.  Admitted Facts-Pretrial Order

                      Finally, though not  less significant,  the
                    parties  conceded in Part  II, Admitted Facts
                    of the Proposed Joint Pretrial Order filed on
                    February  2,   1995  (docket  No.   49)  that
                    Ms. DANIELS  was  a  patient  of  Dr.  RAFAEL

                                         -10-

                    S NCHEZ  MONSERRAT  from May  21,  1990 until
                    September 3, 1991.

          Id. at 3-5.  We agree that these facts indicate  that Dr. S nchez
          ___

          continued  to perform acts or omissions related to the furnishing

          of professional medical  services to Daniels after  July 7, 1991,

          thus triggering the subsequent policy, which provides coverage of

          $500,000 per medical incident.

                                         -11-

          II.  Summary Judgment
          II.  Summary Judgment

                    We  review  the  district   court's  grant  of  summary

          judgment  de novo,  and  will uphold  that determination  "if the
                    _______

          record,  viewed  in the  light  most favorable  to  the nonmoving

          party, shows that  'there is no genuine issue as  to any material

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

          matter of law.'"   Continental  Ins. Co. v.  Arkwright Mut.  Ins.
                             _____________________     ____________________

          Co., 102 F.3d 30, 33 n.4 (1st Cir. 1996) (quoting Fed. R. Civ. P.
          ___

          56(c)).  Faced  with a properly documented  motion, the nonmovant

          must  establish the existence of a genuine issue of material fact

          in order to avoid  the entry of an adverse judgment.   Garside v.
                                                                 _______

          Osco Drug, Inc., 895 F.2d 46, 48 (1st Cir. 1990).
          _______________

                    Daniels attacks the  district court's grant  of summary

          judgment on various grounds, which we will consider in turn.

                    A.  Obvious malpractice
                    A.  Obvious malpractice

                    Dr. S nchez'  AHDM personnel  records indicate  that he

          maintained hospital privileges during the course of his treatment

          of Daniels.   Under  Puerto Rico  law, a  hospital's relationship

          with doctors  to whom  it  grants hospital  privileges must  meet

          several requirements.  The  obligation that Daniels suggests AHDM

          failed  to meet  here,  such  that  AHDM  would  be  jointly  and

          severally liable for Dr. S nchez' malpractice, requires hospitals

          to monitor the work of  physicians with hospital privileges,  and

          to  intervene when  possible in  the face  of an  obvious  act of

          medical malpractice.   See M rquez Vega  v. Mart nez Rosado,  116
                                 ___ ____________     _______________

                                         -12-

          P.R.R.  489,  500 (1985);  see  also Carlos  J.  Irizarry Yunqu ,
                                     _________

          Responsabilidad Civil Extracontractual 253 (1996).
          ______________________________________

                    Beyond her conclusory  allegations to  the effect  that

          Dr. S nchez' malpractice  was so  obvious that AHDM  staff should

          have  intervened, Daniels  fails to  present sufficient  facts to

          show that there is a "genuine issue for trial."  LeBlanc v. Great
                                                           _______    _____

          American Ins.  Co., 6 F.3d 836, 841-42 (1st Cir. 1993).  Although
          __________________

          Daniels  directs our attention to the deposition testimony of her

          experts,  all of  whom agreed  that the  diagnosis of  asthma was

          incorrect,  none of  this deposition  testimony raises  a genuine

          issue as  to whether any act of malpractice by Dr. S nchez was so

          obvious  that AHDM should have  intervened.  The  only mention of

          "obviousness" in  the deposition testimony comes  from Dr. Harold

          Nelson,  one  of  Daniels'  experts.    He states  that  Daniels'

          osteoporosis and  her Cushingoid  state were obvious  symptoms of

          excessive  corticosteroid   use.    That  the   symptoms  Daniels

          exhibited after corticosteroid treatment were  the obvious result

          of excessive use of  the steroid does not sufficiently  raise the

          issue of whether those symptoms were the obvious result of an act

          of  malpractice.   Daniels  did not  meet  her burden  of  coming

          forward with concrete  facts that  would give rise  to a  genuine

          issue of material fact regarding AHDM's liability.

                    B.   Negligence of AHDM Staff Doctors and Nurses
                    B.   Negligence of AHDM Staff Doctors and Nurses

                    Daniels next  argues that  the district court  erred in

          finding  that  AHDM's  doctors  did not  engage  in  malpractice.

          Daniels  failed  to press  this  contention  before the  district

                                         -13-

          court.   Because  Daniels' Opposition  to Defendants'  Motion for

          Summary  Judgment  fails  to  squarely raise  any  contention  of

          specific  malpractice on  the  part of  AHDM's medical  staff, we

          generally  will not  consider such  an argument  on appeal.   See
                                                                        ___

          Grenier v.  Cyanamid Plastics, Inc.,  70 F.3d 667,  678 (1st Cir.
          _______     _______________________

          1995) (recognizing that, by failing to present an argument in his

          opposition  to   summary  judgment  below,  appellant  failed  to

          preserve the argument for appeal).

                    Moreover, her argument is  without merit.  She premises

          AHDM's  liability on the opinion of her expert, Dr. Alvarez, that

          AHDM  staff members  should have  questioned Dr.  S nchez' faulty

          diagnosis and that, had they done so, her result would have  been

          different.     Daniels   misconstrues  Dr.   Alvarez'  deposition

          testimony.   Although  Dr. Alvarez  noted that  nurses frequently

          question  doctors' practices  and  that it  did  not appear  that

          AHDM's nurses had questioned  Dr. S nchez, immediately thereafter

          Dr. Alvarez  stated  that he  had no  opinion  as to  whether the

          nurses  or hospital  staff were  negligent.   This is  hardly the

          forceful  evidence of negligence that Daniels makes it out to be,

          and certainly does not raise a genuine issue as to whether AHDM's

          staff was negligent.

                    C.   Whether Dr. S nchez was an independent contractor
                    C.   Whether Dr. S nchez was an independent contractor

                    Daniels contends that the district court misinterpreted

          our  opinion in  Su rez Matos  v. Ashford  Presbyterian Community
                           ____________     _______________________________

          Hosp., 4 F.3d 47 (1st Cir. 1993), when it found that AHDM was not
          _____

          liable because Dr. S nchez  was merely an independent contractor.

                                         -14-

          Daniels argues that under Su rez Matos, a hospital is liable when
                                    ____________

          a negligent  doctor is more  than a mere  "independent contractor

          having  no other  relationship with  the hospital."   Id.  at 52.
                                                                ___

          Daniels  takes this quotation out of context.  The relevant quote

          reads:

                    While   strictly,   perhaps,  that   decision
                    [M rquez Vega v. Mart nez Rosado,  116 D.P.R.
                     ____________    _______________
                    489,  500  (1985)] contained  dictum  that we
                    might distinguish, and  certainly we need not
                    adopt plaintiff[']s contention that  it would
                    impose   liability  in   the   case   of   an
                    independent   contractor   having  no   other
                    relationship  with the hospital,  it is clear
                    here that granting  staff privileges  coupled
                    with  a joint  sharing in  profits,  left the
                    hospital fully responsible.

          Id.  The  Su rez Matos  opinion, which applies  to situations  in
          ___       ____________

          which the hospital has granted staff privileges to and engages in

          a profit-sharing relationship with  a negligent physician to whom

          it  refers  a  patient, did  not  discuss  the  situation Daniels

          presents here.

                    Furthermore, the situation  dealt with in Su rez  Matos
                                                              _____________

          was  markedly  different from  the case  before  us.   There, the

          patient   sought the assistance  of the hospital  on an emergency

          basis.    Id.  at 48.   The following  day, a  uterine tumor  was
                    ___

          removed  and was examined by a pathologist on the hospital staff.

          Id.   The pathologist misdiagnosed the tumor  as benign.  Id.  By
          ___                                                       ___

          referring the tumor  to the  staff doctor, the  hospital was,  in

          effect,  certifying the  competence  of that  doctor.   The  same

          cannot  be said of  AHDM, which  did not  advise Daniels  to seek

          treatment from Dr. S nchez.

                                         -15-

                    Daniels further  argues that Dr. S nchez  was more than

          an  independent contractor of AHDM and, thus, that AHDM is liable

          for  his malpractice.   Daniels  misconstrues the  application of

          Puerto  Rico's independent contractor law.   In M rquez Vega, the
                                                          ____________

          Puerto Rico Supreme Court visited this very issue:

                    Under  the  second  alternative  --  where  a
                    person goes directly to a physician's private
                    office, agrees with him  as to the  treatment
                    he  or she is going to receive, and goes to a
                    given    hospital    on    the    physician's
                    recommendation     merely     because    said
                    institution  is  one  of  several  which  the
                    physician has the  privilege of using  -- the
                    situation  is somewhat different.  Under this
                    factual  framework,   the  main  relationship
                    established is between the "patient"  and the
                    physician, while the relationship established
                    between the patient and  the hospital is of a
                    supplementary and incidental nature.  In this
                    case, as  a rule, the hospital  should not be
                          __________
                    held liable  for the exclusive  negligence of
                    an  unsalaried physician,  who was  first and
                    foremost entrusted with the patient's health.

          116  D.P.R. at  499 (emphasis  in original);  see also  Carlos J.
                                                        ________

          Irizarry  Yunqu ,  Responsabilidad Civil  Extracontractual 252-53
                             _______________________________________

          (1996).

                    Daniels admitted  in her deposition testimony  that she

          relied primarily on Dr.  S nchez for her diagnosis and  treatment

          and "primarily entrusted [to him] the  diagnosis and treatment of

          her  respiratory condition."   Deposition of Linda Daniels-Recio,

          July 26, 1993, at 113.  She  also indicated that she did not rely

          on AHDM's doctors  or staff  for diagnosis and  treatment of  her

          respiratory  problems.    Id.   at  113-14.    Finally,  Daniels'
                                    ___

          admissions  to AHDM were at  the instruction of  Dr. S nchez, who

          was not a  salaried employee of AHDM.  These facts certainly fall

                                         -16-

          within  the scope  of the  discussion in  M rquez Vega,  and AHDM
                                                    ____________

          cannot  be held  liable  on a  theory  of independent  contractor

          liability.5

                    Having addressed  and  found lacking  all  of  Daniels'

          claims  regarding  the  district  court's  direction  of  summary

          judgment in AHDM's favor, we affirm.

                                      CONCLUSION
                                      CONCLUSION

                    For  the  foregoing  reasons, we  affirm  the  district
                                                      affirm
                                                      ______

          court's determination of policy coverage and its grant of summary

          judgment in favor of AHDM and Evanston.

                              
          ____________________

          5  Indeed,  the Puerto Rico  Supreme Court stated  that, in  this
          situation, it  is not the  doctor, but the  hospital that is  the
          independent contractor:

               [T]he cited case [relied upon by the lower court] deals
               with  the benefits  derived by  the principal  from the
               work performed  by the  independent contractor.   Under
               the  alternative we  are  discussing now  -- where  the
               patient  first goes  to the  physician and then  to the
               hospital  on  the  physician's  recommendation  --  the
               physician would be the principal and the hospital would
               then be the "independent contractor."

          M rquez Vega, 116 D.P.R. at 499.
          ____________

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