Court Opinion

ID: 3189610
Source: CourtListenerOpinion
Date Created: 2016-03-29 20:04:07.253802+00
Date Added: 2024-06-11T07:39:05.240045
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REPORTED

  IN THE COURT OF SPECIAL APPEALS

              OF MARYLAND

                   No. 1687

            September Term, 2014

______________________________________

               JAN CRYSTAL

                       v.

   MIDATLANTIC CARDIOVASCULAR
      ASSOCIATES, P.A., ET AL.

______________________________________

      Krauser, C.J.,
      Berger,
      Leahy,

                  JJ.
______________________________________

         Opinion by Krauser, C.J.
______________________________________

      Filed: March 29, 2016

*Arthur, Kevin, J. did not participate in the
Court’s decision to report this opinion pursuant
to Md. Rule 8-605.1.
       Jan Crystal, appellant, filed a claim with the Health Care Alternative Dispute

Resolution Office, against appellees: Midatlantic Cardiovascular Associates, P.A.

(“Midatlantic”); St. Joseph Medical Center, Inc. (“SJMC”); and Mark G. Midei, M.D.

(“Dr. Midei”), based upon the implantation of an allegedly unnecessary stent in Crystal’s

left anterior descending coronary artery (which we shall, as the parties do, refer to as the

“LAD.”) When arbitration was waived, Crystal filed a complaint in the Circuit Court for

Baltimore County, alleging medical malpractice, fraud by intentional misrepresentation,

and fraud by concealment.1 The claim of medical malpractice was alleged as to all three

health care providers, but the claim of fraud by misrepresentation was brought against only

Dr. Midei, and the claim of fraud by concealment was directed at only SJMC.

       After discovery was concluded by the parties, the circuit court granted appellees’

motions for summary judgment, concluding that there was no evidence to support Crystal’s

claim of fraud by intentional misrepresentation, against Dr. Midei, or his claim of fraud by

concealment, against SJMC. It, then, as a consequence of having disposed of Crystal’s

fraud claims, granted summary judgment as to his remaining medical malpractice claims

against Midatlantic, SJMC, and Dr. Midei, as Crystal’s fraud claims, having been disposed

       1
         Initially, Crystal’s complaint alleged six claims. The first three—medical
malpractice (count I, against Midatlantic, SJMC, and Dr. Midei), intentional
misrepresentation (count II, against Dr. Midei), and fraudulent concealment (count III,
against SJMC)—are the subject of this appeal, as the circuit court granted summary
judgment, on all three of these claims, in favor of appellees. The three other claims—
negligent hiring and retention (count IV, against Midatlantic), negligent supervision (count
V, against Midatlantic), and loss of consortium (count VI, against Midatlantic, SJMC, and
Dr. Midei)—were dismissed by the court, without prejudice, following the hearing on
appellees’ motions for summary judgment, and are not relevant to this appeal.
of on summary judgment, could no longer be deemed to have tolled the statute of

limitations, which had long since run on his medical malpractice claims.

       From those rulings, Crystal noted this appeal, contending that the court had erred in

granting appellees’ motions for summary judgment as to all of his claims, and thus his

claims of fraud and medical malpractice should be resurrected by this Court. For the

reasons set forth below, we shall affirm.

                                              I.

                                        Background

       In October of 2004, after experiencing chest pain, shortness of breath, and a feeling

of tightness in his chest, Crystal underwent a “cardiac catheterization,”2 a procedure used

to evaluate and diagnose cardiovascular conditions.         During that procedure, it was

discovered that there was a “stenosis”—that is, an abnormal narrowing3—of Crystal’s

LAD. The level of stenosis in that artery had reached 95%. To address that condition, a

stent was placed in Crystal’s LAD.

       2
         A cardiac catheter is a catheter “that can be passed into the heart through a vein or
artery” to, among other functions, “inject contrast media.” Stedman’s Medical Dictionary
327 (28th ed. 2006). The procedure is used “mainly in the diagnosis and evaluation of
congenital, rheumatic, and coronary artery lesions and to evaluate systolic and diastolic
cardiac function.” Id.
       3
        Stenosis is a “stricture of any canal or orifice.” Stedman’s Medical Dictionary
1832 (28th ed. 2006).

                                              2
       Yet, notwithstanding the successful completion of that procedure, Crystal continued

to experience shortness of breath. Consequently, his cardiologist recommended that he

undergo another cardiac catheterization. That second catheterization was to be performed

by appellee, Dr. Midei, a cardiologist with appellee, Midatlantic.4

       Before undergoing this procedure, however, Crystal signed, on November 4, 2004,5

a “Cardiac Catheterization Laboratory Procedure Consent Form,” which authorized Dr.

Midei “to perform one or more” of a number of medical procedures, including a “heart

catheterization,” a “coronary angiography,” and a “stent implantation.” Specifically, it

stated, in pertinent part:

       I consent to and authorize Dr. Mark Midei and his/her assistants to perform
       one or more of the following procedures:

       Heart catheterization and coronary angiography, possible coronary
       angioplasty-type procedures (angioplasty, atherectomy, stent placement . . .),
       and possible peripheral angiography. Please read the explanations below.

               ***

       Heart catheterization with coronary angiography is a diagnostic
       procedure to define the presence, nature, and extent of heart disease. The
       physician inserts a small tube or catheter into an artery and/or vein in the leg
       or arm and advances it to the heart. The physician will inject dye through
       the catheter, take pictures of the arteries or grafts to the heart, and measure
       pressures in the heart. The results of this test will help determine if
       medication, an angioplasty-type procedure, or bypass surgery is the best
       treatment.

       4
         Pursuant to an agreement between Midatlantic and SJMC, Dr. Midei served as the
director of SJMC’s cardiac catheterization “lab.”
       5
         This consent form was signed, by Crystal, prior to the medical procedure in
question, on November 4, 2004. Another consent form, not relevant to this appeal, was
signed on the day of the procedure, November 22, 2004.
                                              3
              ***

       Coronary or peripheral angioplasty-type procedures (angioplasty,
       atherectomy, stent placement) are therapeutic procedures to open blockages
       in coronary or peripheral arteries or bypass grafts. The physician will
       perform coronary or peripheral angiography, then advance a thin guidewire
       across the blockage and then select the most appropriate procedure(s) to open
       the blockage . . . . Stent implantation is a procedure where the physician
       inserts a metal stent (mesh-like tube) at the site of the blockage which is left
       in place to hold the artery open.

              ***

       Notably, the form did not contain any requisite degree of blockage that would

require or preclude the implantation of a stent, but instead left the decision, of whether to

place a stent, to the medical judgment of Dr. Midei.

       Notwithstanding Crystal’s pre-operative consent to the procedure, it was Crystal’s

claim that Dr. Midei, though not required to do so, informed him, during the course of the

procedure, but before the implantation of the stent, of the level of stenosis in his LAD.

According to Crystal, Dr. Midei, before placing the stent, advised him, as he lay on the

operating table, that the stenosis in question had reached 70% (though the laboratory report

he later prepared suggested an even higher level of stenosis, that is, 80%) and that he would

need a stent to avoid a complete blockage of the artery. Dr. Midei then placed another stent

in Crystal’s LAD.

       At his deposition, nearly ten years later, Crystal, in recalling the deliverance of that

advisement by Dr. Midei, testified as follows:

       [Counsel]: Prior to the beginning of the cardiac catheterization procedure that
       [Dr. Midei] performed on November 22, do you remember talking to him?

                                              4
       [Crystal]: Just in the lab.

       [Counsel]: I understand. On that morning before he started the catheterization
       procedure, do you remember talking to Dr. Midei?

       [Crystal]: No.

       [Counsel]: Do you remember someone going over a consent form with you?

       [Crystal]: I don’t recall.

       [Counsel]: Do you know if you signed a consent form?

       [Crystal]: I don’t recall. I am sure I had to, but I don’t recall.

       [Counsel]: What do you remember Dr. Midei saying during the procedure, if
       anything?

       [Crystal]: He pretty much started the same way that Dr. Brinker did. I’m
       going to do this. You’re going to feel that. And it wasn’t long into the
       procedure that he told me I had a 70 percent blockage in my LAD. Now those
       letters sounded pretty familiar to me.

       [Counsel]: Okay you remember him saying anything else?

       [Crystal]: You would need this stented to keep it from blocking completely.

       [Counsel]: Are you paraphrasing what you remember that he told you or are
       those Dr. Midei’s exact words?

       [Crystal]: I can’t remember back 10 years. So I’m assuming. I’m
       paraphrasing.

       Five years after the stent implantation at issue, in 2009, Crystal read a newspaper

article suggesting that Dr. Midei had been performing “unnecessary” stent implantation

procedures. That article led Crystal to contact an attorney. Two years later, in 2011, almost

seven years after the stent implantation procedure had been performed by Dr. Midei,

Crystal filed a claim, with the Health Care Alternative Dispute Resolution Office, against

                                               5
the three appellee health-care providers. Crystal filed, with that claim, a certificate of

qualified expert, naming Herbert Fischer, M.D., as that expert, and Dr. Fischer’s report. In

both the certificate and his report, Dr. Fischer opined that Dr. Midei had breached the

standard of care applicable to stent implantation procedures by implanting a stent when

there had been “insufficient evidence to justify” such a procedure. Arbitration was

thereafter waived, and the case was transferred to the Baltimore County circuit court.

                            Summary Judgment Proceedings

       In the Baltimore County circuit court, appellees subsequently moved for summary

judgment, contending that Crystal had failed to generate a dispute of material fact as to his

claims of fraud by intentional misrepresentation and fraud by concealment. And, because,

in their view, there was no evidence of fraud, the five-year medical malpractice statute of

limitations, which had long since run on Crystal’s medical malpractice claims, had not been

tolled by those fraud claims and, therefore, those medical malpractice claims should be

dismissed, by the court, as time-barred.

       Crystal responded to appellees’ motions by asserting that there was a dispute of

material fact as to, at least, his claim of fraud by intentional misrepresentation because

there was evidence that Dr. Midei had “deliberately misled” Crystal to induce him to

undergo the stent implantation procedure in question. That evidence, Crystal pointed out,

was Dr. Fischer’s deposition testimony that, at the time Dr. Midei implanted the second

stent, the level of arterial stenosis was “about a 30 percent stenosis at the maximum,”

                                             6
though, at the same deposition, he later increased that estimate of stenosis to 30-40%.6 And

that testimony, noted Crystal, contradicted Dr. Midei’s statement that Crystal had a 70%

stenosis in his artery, as well as Midei’s subsequent description of an 80% stenosis in his

laboratory report. “A jury could readily conclude” from that “large discrepancy,” avowed

Crystal, that Dr. Midei “knew at the time of the stent implantation that there was nowhere

near” a 70% or 80% stenosis and that he “deliberately misled” Crystal by so stating and

thereby inducing Crystal to undergo the stent implantation procedure.

       Such evidence, Crystal further asserted, created a “jury question” as to whether Dr.

Midei committed fraud, by misrepresenting the actual level of stenosis in Crystal’s LAD,

which, if proved, would toll the statute of limitations as to his medical malpractice claim.

Crystal then urged the court to deny summary judgment as to his claim of fraud by

concealment, which was alleged solely as to SJMC, because the medical center was, he

claimed, “[vicariously] liable for the fraudulent concealment acts of Dr. Midei.”7

       The circuit court, following a hearing on appellees’ motions, granted summary

judgment, as to all three counts. In so doing, the court explained that, as to the claim of

       6
         During his deposition, Dr. Fischer opined that there was about a 30% stenosis of
Crystal’s LAD. Later in that deposition, however, Dr. Fischer drew a diagram showing the
area of the stenosis shown on the angiogram. In that diagram he wrote his estimate of the
stenosis as “20-(30-40% max).”
       7
         In making that request, Crystal abandoned the allegation that he originally made
in his complaint, where he asserted that SJMC “had a duty to disclose” to Crystal, Dr.
Midei’s purported “history of negligently and fraudulently advising patients to undergo
unnecessary stent procedures and/or negligently and fraudulently placing stents in patients
without proper consent.”

                                             7
fraud by misrepresentation against Dr. Midei, it was not persuaded by Crystal’s contention

that the “difference of opinion” between Dr. Fischer and Dr. Midei, regarding the level of

stenosis in his LAD, constituted evidence that Dr. Midei had, knowingly or with reckless

indifference, made a false statement to Crystal with respect to that level. It therefore

granted summary judgment as to that count, because Crystal, in its view, had “failed to

proffer evidence of a genuine issue for trial on: whether Dr. Midei knowingly made a false

representation; whether he intended to defraud Mr. Crystal; and/or whether Mr. Crystal

relied on misrepresentations by Dr. Midei in consenting to the procedure.”

       The court also explained that it was granting summary judgment as to the claim

against SJMC for fraud by concealment because: First, it was “not aware of any authority

for the proposition that SJMC or any health care provider, generally, has a duty to disclose

to patients prior instances of medical malpractice,” and, second, “even if [SJMC] had a

duty to disclose this information, there is no evidence that [SJMC] had information to

disclose at the time of Crystal’s procedure.” Then, given “the absence of sufficient

evidence of fraud,” the court determined that the five-year statute of limitations period had

run on Crystal’s medical malpractice claims, having not been tolled by fraud, and dismissed

those claims as time-barred.

                                             8
                                              II.

                                    Standard of Review

       Maryland Rule 2-501 provides that summary judgment shall be entered “in favor of

or against the moving party if the motion and response show that there is no genuine dispute

as to any material fact and that the party in whose favor judgment is entered is entitled to

judgment as a matter of law.” In other words, the circuit court must first determine

“whether there is a dispute as to a material fact sufficient to require the issue to be tried.”

Frederick Rd. Ltd. P’ship v. Brown & Sturm, 360 Md. 76, 93 (2000). If there is no such

dispute and if the nonmoving party has “failed to make a sufficient showing on an essential

element” of its claim, for which it has the burden of proof, summary judgment is then

appropriate in favor of the movant. Cent. Truck Ctr. Inc. v. Cent. GMC, Inc., 194 Md. App.
375, 386 (2010) (internal citation and quotation marks omitted)

       In assessing the propriety of a grant of summary judgment, we apply a de novo

standard of review. River Walk Apartments LLC. v. Twigg, 396 Md. 527, 541 (2007). In

conducting that assessment, we consider the facts and all reasonable inferences that may

be drawn from those facts, in a light most favorable to the nonmoving party. Frederick

Rd. Ltd. P’ship, 360 Md. at 93-94. Our review is limited, however, solely to the grounds

upon which the circuit court granted summary judgment. River Walk Apartments, 396 Md.

at 541–42.

                                              9
                                            III.

                        Fraud By Intentional Misrepresentation

       Crystal contends that the circuit court erred in granting summary judgment as to his

claim of fraud by intentional misrepresentation against Dr. Midei.          Specifically, he

maintains that there was a genuine issue of material fact as to whether Dr. Midei had

deliberately misstated, or had done so with reckless indifference, the degree of stenosis in

Crystal’s LAD, so as to induce Crystal to agree to the stent implantation procedure that

was ultimately performed. In support of that claim, he suggests that there was “too great a

discrepancy” between Dr. Midei’s and Dr. Fischer’s opinions about the percentage of

stenosis in Crystal’s LAD for Dr. Midei’s statement, that there was a 70% stenosis, to have

been anything but an intentional misrepresentation of the level of stenosis to induce Crystal

to undergo the stent implantation procedure at issue.

       To prevail on a claim of fraud, a plaintiff must show, “by clear and convincing

evidence,” the following elements, the second of which we have bolded as it is central to

this appeal:

       1. That the defendant made a false representation to the plaintiff;
       2. That its falsity was either known to the defendant or that the
       representation was made with reckless indifference as to its truth;
       3. That the misrepresentation was made for the purpose of defrauding the
       plaintiff;
       4. That the plaintiff relied on the misrepresentation and had the right to rely
       on it; and
       5. That the plaintiff suffered compensable injury resulting from the
       misrepresentation.

       E.g. VF Corp. v. Wrexham Aviation Corp., 350 Md. 693, 703-04 (1998) (emphasis

added).

                                             10
       It is, as noted, the second element (or the “knowledge element”) of fraud that is at

issue here. Thus, the question before us is: Did Crystal present sufficient evidence to

generate a genuine dispute of material fact as to whether Dr. Midei knew that the statement

he made to Crystal was false or that Dr. Midei was “recklessly indifferent” with respect to

the truthfulness of that statement. In addressing that question, we are guided by the

principle that “[n]egligence or misjudgment, however gross, does not satisfy the knowledge

element” of fraud. VF Corp., 350 Md. at 704 (internal quotation marks and citation

omitted).

       Crystal’s claim of fraud by intentional misrepresentation rests entirely on the

competing diagnoses of Dr. Midei, Crystal’s treating cardiologist, and Dr. Fischer,

Crystal’s “qualified expert.” In both the certificate of qualified expert and the report,

accompanying that certificate, which were filed with Crystal’s claim, Dr. Fischer opined

that Dr. Midei had breached the standard of care by placing a stent “without reasonable

evidence that [it] was medically necessary.” In reaching that conclusion, Dr. Fischer

reviewed Crystal’s medical file “regarding the catheterization and stent placement by Dr.

Midei,” including the angiogram for that procedure. He deponed that, in reviewing the

angiogram, he did not “see anything that would even come close” to the percentage of

stenosis Dr. Midei had recorded. According to Dr. Fischer, Crystal’s LAD had about a 30

to 40% stenosis, not the 70% indicated by Dr. Midei. “[Y]ou never treat coronary artery

disease with stents,” Dr. Fischer declared, “unless there is severe stenosis.” But, at no time

did he specify what level of stenosis constitutes “severe stenosis” or what a reasonable

                                             11
margin of error might be in reading an angiogram with the naked eye, the only available

tool for making such an assessment at that time.

       A “plaintiff obviously does not establish” fraud by merely showing that “objectively

false representations about the diagnosis and treatment” were made. Geisz v. Greater Balt.

Med. Ctr., 313 Md. 301, 330 (1988). Fraud, as noted, does not “encompass liability for

negligent or grossly negligent representations.” Ellerin v. Fairfax Sav., F.S.B., 337 Md.
216, 238–39 (1995). Similarly, the Court of Appeals has instructed that “the fraud

exception” to the statute of limitations, upon which Crystal relies in support of his

contention that the limitations on his medical malpractice claims had been tolled, “cannot

be satisfied by evidence which demonstrates no more than negligence.” Geisz, 313 Md.
301 at 328.

       Crystal has provided no evidence that Dr. Midei knew his assessment of stenosis,

whether it be 70 or 80%, was incorrect. The disparity between Dr. Fischer’s testimony and

the statements made by Dr. Midei suggests, at most, that Dr. Midei may have been

negligent, perhaps even grossly negligent, in his diagnosis. And, as observed earlier, “a

difference of opinion concerning the applicable standard of care” is insufficient to establish

fraud. Geisz, 313 Md. at 330.

       Crystal further suggests that an inference of fraud can be drawn from the

discrepancy between Dr. Midei’s statement during catheterization, when he stated there

was a 70% stenosis, and his laboratory report, which stated that the level of stenosis was

80%. The difference in the two evaluations by Dr. Midei was evidence, Crystal claims,

that Dr. Midei knew that his assessment of 70% was false.

                                             12
       But there was no evidence that that discrepancy reflected anything more than a

mistake made by Dr. Midei in recalling the level of stenosis shown by the angiogram, or a

transcription or dictation error, or a misunderstanding by Crystal about what Dr. Midei had

originally said, during the procedure, regarding the level of stenosis, or, perhaps, a lapse in

memory when, during his deposition, Crystal “paraphrased” what Dr. Midei had said to

him many years before. In any event, the mere difference between Dr. Midei’s statement

to Crystal during the procedure and the number recorded in the report does not, without

more, permit a reasonable inference to be drawn that Dr. Midei knew his assessment of

70% stenosis was too high. In fact, it may suggest that Dr. Midei believed the level of

stenosis in Crystal’s LAD was at least 70 percent if not more.

       Unable to show that Dr. Midei knew his assessment of 70% stenosis was false,

Crystal’s only remaining option was to present evidence showing that Dr. Midei was

recklessly indifferent to the truth of his assessment. In our view, there was no evidence

that he was. The difference of opinion, as we explained, may have been the result of a

mistake or of a misjudgment amounting to negligence or even gross negligence, but there

was no evidence of fraud.

       But, Crystal cites Geisz v. Greater Baltimore Med. Ctr., 313 Md. 301 (1988), for a

contrary proposition. Steven Geisz had been diagnosed with “Hodgkin’s disease,” a form

of cancer. Geisz, 313 Md. at 305. His physician, George Richards, M.D., directed that

Geisz receive several courses of radiation and chemotherapy treatments. Id. at 309.

Unfortunately, after receiving those treatments, Geisz succumbed to that disease. Id. at

304.

                                              13
       Nearly ten years after his death, Geisz’s former wife8 read a newspaper article,

detailing medical malpractice actions that had been filed, by other patients of Dr. Richards,

against him. Id. at 306. “As a result of her having read [this] newspaper article,” Geisz’s

former wife brought a wrongful death action, on behalf of their son, against Dr. Richards

and the Greater Baltimore Medical Center, alleging medical malpractice, for courses of

treatment that were “improperly conceived and administered.” Id. at 304–07.

       Although the limitations period, on its wrongful death claim, appeared to have run,

the estate maintained that it had not because it had been tolled by fraud. Id. at 307-08. The

fraud alleged by the estate was that Dr. Richards had misrepresented to Geisz and his

former wife that “he had given [Geisz] every treatment available in the country, the best of

treatments,” but for some reason Geisz had not responded to those remedial measures,

when, in fact, the courses of treatment received by Geisz “from technicians acting at the

direction of, and under the supervision of Dr. Richards, courses of treatment which the

plaintiffs allege were improperly conceived and administered.” Id. at 306-11. This

statement, Geisz’s estate claimed, “kept [the estate] in ignorance of the cause of action”

that it may have had against Dr. Richards and the medical center. Id. at 307-08.

       The defendant doctor and the medical center then moved for summary judgment,

contending that the claim was time-barred and that the statement at issue, made by Dr.

Richards, did not amount to fraud. Id. at 308. In response, the estate, in an attempt to show

       8
       Steven Geisz “had obtained a divorce” from his former wife, Elaine Geisz, a few
months before his death. Id. at 305.

                                             14
that the statement was made fraudulently, presented the deposition testimony of Dr.

Richards, from another malpractice case pending against him. Id. at 311-12. In that

deposition, Dr. Richards made statements suggesting, by implication, that “portal films,”

that he had requested, may not have been done in the course of Mr. Geisz’s treatment,

which were necessary in determining whether the dispensed radiation had “reach[ed] into

the areas . . . intended for radiation.” Id. at 312.

       Geisz’s estate also presented reports, from its medical experts, stating that, in

Geisz’s case, the “treatment plans, calculations of dosages, and portal films were not done.”

Id. at 313. This evidence, the estate suggested, showed that Dr. Richards had no factual

basis for his statement to Steven Geisz and his former wife, assuring them that he had given

Geisz the best possible treatment—a statement the estate relied upon in contending that the

statute of limitations had been tolled on their claims by fraud. Id. at 307-08.

       After the circuit court granted summary judgment in favor of the defendants, the

Court of Appeals reversed that judgment, holding that the estate’s evidence generated a

“fact question” of “whether Dr. Richards had a basis for representing that the particular

cancer in Geisz had been treated, but for some inexplicable reason had withstood

treatment.” Id. at 332. The Court observed that the estate had presented evidence that it

was “impossible for Dr. Richards to determine whether the desired treatment had actually

been received,” despite his statements to Geisz that he had given him every available

treatment. Id. at 333–34. That evidence, if believed, “could support,” declared the Court,

“a finding of reckless indifference to the truth” and thus a claim of fraud. Id. at 334.

                                               15
       But Geisz is clearly distinguishable from the instant case. Unlike what occurred in

Geisz, Dr. Midei did not tell Crystal that he had a 70% stenosis in his LAD without the

appropriate test, nor did Dr. Midei make that statement while foregoing other necessary

tests to establish the level of stenosis. Instead, Crystal’s claim of reckless indifference rests

entirely on the supposition that Dr. Midei was wrong—perhaps very wrong—in his

assessment of the level of stenosis. But, as stated previously, evidence of negligence,

“however gross,” does not rise to the level of reckless indifference necessary to establish

fraud. VF Corp., 350 Md. at 704 (internal citations omitted).

       Moreover, it is worth noting several ways in which Dr. Fischer’s testimony clearly

stops short of crossing the threshold from negligence into gross negligence, let alone fraud.

First, Dr. Fischer did not explain what the boundaries of stent-requiring stenosis are, that

is, at what percentage of blockage should a doctor begin to consider placing a stent. Thus,

while Dr. Fischer did opine that Dr. Midei’s assessment of the stenosis fell below the

standard of care, it is unclear exactly how unreasonable that assessment was. Second,

although Dr. Fischer stated that “you never treat coronary artery disease with stents unless

there is severe stenosis,” he never indicated what minimum percentage of blockage

constitutes “severe” stenosis. Third, there is presumably a margin of error involved when

a doctor estimates the percentage of stenosis in an artery from an angiogram, particularly

                                               16
where that evaluation is performed, as was the case here, by the naked eye.9 But, Dr.

Fischer did not explain what that typical margin of error would be. Fourth and finally, Dr.

Fischer offered no opinion as to Crystal’s prior medical history and whether his prior

instances of severe stenosis would lower the level at which a doctor would recommend the

implantation of a stent.

       In sum, although the inference could be drawn, from the evidence presented below

that negligence had occurred, that has no bearing on Crystal’s fraud claim. Fraud requires

knowledge of the falseness of the statement, or at least a reckless indifference as to the

truthfulness of the statement made by the defendant, whereas negligence does not. And,

without evidence that Dr. Midei knowingly misstated the percentage of stenosis in

Crystal’s LAD, or that he was recklessly indifferent to what that percentage of stenosis

was, Crystal’s claim of fraud by misrepresentation could not withstand summary judgment

and thus the circuit court did not err in granting that judgment.

       9
         The issue of “interreader variability” was raised at the hearing that was held on the
motions for summary judgment. “Interreader variability,” as explained by the circuit court,
assumes that different experts “will have a variability in their reading of the stenosis by up
to 20 percent,” such that one expert reviewing an angiogram could see a stenosis of 60%
while another expert reviewing the same angiogram could see a stenosis of 80%. For the
purpose of the motions for summary judgment, Crystal refused to concede “that there [was]
a 20 percent interreader variability” in this case, but he did not dispute that “interreader
variability” is always a factor in such matters.
                                             17
                                             IV.

                                 Fraud By Concealment

       We turn now to Crystal’s contention that the circuit court erred in granting summary

judgment, in favor of SJMC, on his claim that the medical center had committed fraudulent

concealment by not disclosing Dr. Midei’s purported history of negligence and fraud. In

addressing this issue, we begin with a brief description of Crystal’s inconsistent, and

somewhat confusing, assertion of that claim. Crystal alleged, in his complaint, that SJMC

was liable for fraud by concealment because, prior to his procedure in 2004, the medical

center had “actual knowledge that Dr. Midei was negligently and fraudulently advising his

patients to undergo unnecessary stent procedures.” Then, later in his complaint, Crystal

stated that SJMC had a “duty to disclose” such information to Crystal, but failed to do so.

After discovery, however, Crystal, in his response to appellees’ motions for summary

judgment, offered a different theory of liability, stating that “SJMC is liable for the

fraudulent concealment acts of Dr. Midei.”

       The circuit court properly granted summary judgment as to the claim of fraud by

concealment. In so doing, the court understandably chose to address only the theory of

liability in Crystal’s complaint, because, as that court put it, it was “not aware of any

authority for the proposition that SJMC or any health care provider, generally, has a duty

to disclose to patients prior instances of medical malpractice.” It then added that “even if

[SJMC] had a duty to disclose this information, there is no evidence that [SJMC] had

information to disclose at the time of Crystal’s procedure.”

                                             18
       On appeal, Crystal concedes, in his brief, that “the court properly found that there

was no evidence that SJMC was on notice of Dr. Midei’s pattern of negligence or fraud

prior to [his] surgery” and that the court was correct in stating that “there is no evidence

that [SJMC] engaged in any misconduct, should have known about misconduct, or should

have investigated any misconduct at the time of [the 2004 procedure].” Nevertheless,

Crystal now contends, as he did in his response to the motion for summary judgment but

not in his complaint, that the circuit court erred in granting of summary judgment as to the

claim of fraud by concealment because “the asserted basis of liability by SJMC under

[fraud by concealment] was the vicarious liability of SJMC for its employee, Dr. Midei,--

not SJMC’s own failure to act.”

       We decline to address Crystal’s suggestion, on appeal, that SJMC was vicariously

liable for Dr. Midei, as that theory of liability contradicts what Crystal stated in his

complaint. Instead, we review the circuit court’s grant of summary judgment based upon

the grounds relied upon in the record. To prevail on a claim of fraudulent concealment, a

plaintiff must show that

          (1) the defendant owed a duty to the plaintiff to disclose a material fact;
          (2) the defendant failed to disclose that fact; (3) the defendant intended
          to defraud or deceive the plaintiff; (4) the plaintiff took action in
          justifiable reliance on the concealment; and (5) the plaintiff suffered
          damages as a result of the defendant's concealment.

Lloyd v. Gen. Motors Corp., 397 Md. 108, 138 (2007) (internal citations omitted). “A

fraudulent concealment claim is caused, in part,” the Court of Appeals has said, “by the

intentional failure to warn. Lloyd, 397 Md. at 138-39. It is clear that the circuit court

properly granted summary judgment because there was no evidence, as even Crystal

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concedes, that SJMC knew or should have known about Dr. Midei’s alleged prior

misconduct.

                                             V.

                                   Medical Malpractice

       Finally, we turn to Crystal’s remaining contention that the circuit court erred in

granting summary judgment as to his medical malpractice claims. Although, Crystal

concedes that he did not file his complaint within the required five-year statute of

limitations period,10 he believes that his claim, contrary to the circuit court’s finding, was

not time-barred because it was tolled by a showing of fraud under § 5-203, of the Courts

and Judicial Proceedings Article of the Maryland Code.

       That tolling provision provides: “If the knowledge of a cause of action is kept from

a party by the fraud of an adverse party, the cause of action shall be deemed to accrue at

the time when the party discovered, or by the exercise of ordinary diligence should have

discovered the fraud.” Md. Code Ann., Cts. & Jud. Proc. § 5-203. The alleged fraud,

Crystal maintains, was Dr. Midei’s purported misrepresentation, during the procedure,

about the 70% level of stenosis in Crystal’s LAD. But, as previously discussed, Crystal

did not present any evidence that Dr. Midei made what could be found to be a fraudulent

       10
         Md. Code Ann., Cts. & Jud. Proc. § 5-109 states, in relevant part, that an “action
for damages for an injury arising out of the rendering of or failure to render professional
services by a health care provider, as defined in § 3-2A-01 of this article, shall be filed
within the earlier of: (1) Five years of the time the injury was committed . . .”
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statement to induce the stent implantation at issue. Therefore, without any evidence of

fraud that would toll the statute of limitations, the circuit court was impelled to find, as it

did, that Crystal’s remaining medical malpractice claims were time-barred.

                                           JUDGMENTS OF THE CIRCUIT COURT
                                           FOR BALTIMORE COUNTY AFFIRMED.
                                           COSTS TO BE PAID BY APPELLANT.

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