Beller v. Health and Hosp. Corp. of Marion County, Indiana, 703 F.3d 388, 392 (2012)

1. Facts

1.1. Parties

1.1.1. Plaintiffs

1.1.1.1. Joshua Beller (minor)

1.1.1.2. Melissa Welch, mother of Joshua

1.1.2. Defendant

1.1.2.1. Health and Hospital Corporation of Marion County, Indiana, d/b/a Wishard Memorial Hospital, d/b/a Wishard Ambulance Service

1.2. What happened

1.2.1. 06/14/2001 Plaintiff Welch went into labor at 34 weeks gestation

1.2.2. Plaintiff called 911 when her water broke and paramedics arrived and assessed her situation

1.2.2.1. Paramedics determined that Plaintiff had a prolapsed umbilical cord

1.2.3. Paramedics attempted to "relieve pressure on the cord"

1.2.3.1. Beller v. Health and Hosp. Corp. of Marion County, Indiana, 703 F.3d 388, 392 (2012)

1.2.4. Paramedics contacted Plaintiff's OBGYN

1.2.4.1. It was agreed that Ms. Welch be transported by ambulance to the closest hospital

1.2.5. Plaintiff was transported to St. Francis Beech Grove emergency room

1.2.5.1. Ms. Welch was examined at Beech Grove but due to the hospital's lack of an appropriate obstetrics department, it was determined that she had to be transported to another facility

1.2.6. Plaintiff was then transported to St. Francis Hospital South

1.2.6.1. Plaintiff Beller was delivered at this facility by c-section

1.2.7. Beller sustained "severe brain damage" due to lack of oxygen

1.2.7.1. Beller v. Health and Hosp. Corp. of Marion County, Indiana, 703 F.3d 388, 392 (2012)

1.3. Procedural history

1.3.1. Plaintiff sued the Defendant on the basis on EMTALA

1.3.1.1. Claim: Defendant did not stabilize Plaintiff during emergency medical situation therefore violating EMTALA

1.3.2. Summary judgement denied for Defendant then later granted

1.3.2.1. Court held that Plaintiffs had not come to the emergency room by being in Wishard ambulance

1.3.2.2. Court held that 2003 EMTALA definition did not change but only clarified 2001 regulation and could be applied to case

1.3.2.2.1. see Rule of Law for further detail on EMTALA policy

1.3.3. Plaintiff appealed

2. Issue

2.1. Whether the Plaintiffs are covered under EMTALA as being considered having "come to the emergency room" while in the Wishard ambulance

2.1.1. whether the 2003 definition is a clarification or a change of the 2001 regulation

2.1.1.1. i.e. whether the 2003 definition can be retroactively applied to this case

3. Rule of Law

3.1. Emergency Medical Treatment and Active Labor Act (EMTALA)

3.1.1. Two main provisions

3.1.1.1. Hospitals must give a medical examination to patients who come into the emergency department seeking medical attention

3.1.1.2. If an emergency condition presents itself. the hospital must stabilize the condition before the patient can be transferred to another facility

3.1.2. 2001 regulation

3.1.2.1. states that a patient is considered as having come to the emergency department if they are on hospital property

3.1.2.1.1. hospital property includes ambulances that are owned and operated by the hospital regardless of the location of said ambulance (i.e. whether or not the ambulance is on the hospital grounds)

3.1.3. 2003 definition

3.1.3.1. states that a person is not considered having come to the emergency room if:

3.1.3.1.1. "the ambulance is operated under communitywide emergency medical service (EMS) protocols that direct it to transport the individual to a hospital other than the hospital that owns the ambulance"

3.1.3.1.2. "the ambulance is operated at the direction of a physician who is not employed or otherwise affiliated with the "hospital that owns the ambulance

3.2. Precedents

3.2.1. Clay v. Johnson, 264 F. 3d 744, 749 (7th Cir.2001)

3.2.1.1. does not reference retroactive application of rules

3.2.1.2. holds that clarifications can be applied to cases "just as a judicial determination construing a statute can be applied..."

3.2.1.2.1. in this case if it is determined that the 2003 regulation is a clarification and not a substantive change then it can be applied

3.2.2. Bowen v. Georgetown University Hospital 488 U.S. 204, 208-09, 109 S.Ct. 468, 102 L.Ed.2d 493 (1988)

3.2.2.1. held that new rules cannot be applied retroactively

3.2.2.2. distinguishes between rules that clarify previous laws and those that create "substantive changes"

4. Analysis

4.1. Plaintiffs' argument

4.1.1. Claim that since the Defendant hospital owned the ambulance, they were considered as coming to the emergency department under EMTALA and should have been treated as such

4.1.1.1. Plaintiffs claim they were entitled to care that would have stabilized their condition before transferring to a hospital

4.1.1.1.1. in this case that would mean delivering the baby

4.1.2. Claim that the 2003 definition is not a clarifier but a change

4.1.2.1. specifically, that the 2 regulations are inconsistent with each other

4.1.2.2. They argue that since EMS protocols were developed after the 2001 EMTALA regulation, the 2003 definition had to have been a substantive change to include newly developed protocols

4.1.2.2.1. i.e. the advent of EMS protocols and their inclusion in the 2003 definition entirely changes what it means to come to the emergency department

4.2. Court determinations

4.2.1. Court determined that the 2003 definition was a clarification of the 2001 definition, not a change

4.2.1.1. In this case the court considers a definition a clarification "unless the prior interpretation of the regulation is 'partly inconsistent' with the later one

4.2.1.1.1. Beller v. Health and Hosp. Corp. of Marion County, Indiana, 703 F.3d 388, 392 (2012)

4.2.1.2. The 2003 definition serves to clarify the statement that an ambulance is hospital property when it is owned and operated by the hospital

4.2.1.2.1. the new definition does not make changes to the 2001 definition but only examines two situations where an ambulance is not operated by the hospital

4.2.1.2.2. therefore the 2003 definition can be applied retroactively

4.2.1.3. Factual considerations

4.2.1.3.1. the title of the 2003 regulation specifically indicated that it was a clarification

4.2.1.3.2. DHHS specifically referred to the new rule as a "proposal to clarify..."

4.2.2. Court determined that the Plaintiffs were missing a critical point in their argument that they were considered as coming to the emergency room because they were in an ambulance owned by the Defendant hospital

4.2.2.1. EMTALA states that the ambulance must be both owned AND operated by the hospital in order to be considered the hospital's property

4.2.2.1.1. in this case, the ambulance was operating under EMS protocols therefore was not operated by the Defendant hospital

5. Conclusion

5.1. The Court affirmed the decision of the district court

5.1.1. the 2003 definition was a clarification and could be retroactively applied to this case

5.1.1.1. Defendant ambulance was not considered hospital property since it was operating under EMS protocols

5.1.1.2. Plaintiffs were not considered as coming to the emergency room

5.1.2. Summary judgement for Defendant

6. Impact

6.1. Several court cases were found that cite Beller v. Health and Hops. Corp. but none that substantially reference or quote it nor are any directly related

6.2. Cases that cite Beller do so in regarding both EMTALA requirements and retroactive application of rules

6.2.1. Driver v. AppleIllinois, LLC, 917 F. Supp. 2d 793, 802 (N.D. Ill. 2013)

6.2.1.1. a case where employees and former employees of Applebees sued them for violations of the Illinois Minimum Wage Law and the Fair Labor Standards Act regarding wages and tips

6.2.1.1.1. the Beller case is mentioned as a precedent in deciding whether a rule is clarifying and whether or not it can be used retroactively though no such decision was needed in the Driver case

6.2.2. McDaniel v. Colvin, No. 12-CV-1000-DRH-CJP, 2014 WL 2442543, at *7 (S.D. Ill. May 30, 2014)

6.2.2.1. a case where the Plaintiff is denied SSI benefits for disability claims and sues to obtain them

6.2.2.1.1. there is a discussion of whether or not the Plaintiff had been denied emergency treatment due to inability to pay and the Beller case is mentioned as a source for EMTALA information

6.3. No negative treatment

7. Importance

7.1. This case proves the importance of the distinction between hospital property and not hospital property when considering how to treat emergency patients

7.1.1. ambulances should have a clear idea of which protocols they are acting under

7.1.1.1. EMS protocols vs. physician directives vs. owning hospital directives

7.2. This case also demonstrates the importance of health care organizations keeping current with rules, regulations and definitions of EMTALA and other relevant health care policies

8. Influence

8.1. Most hospitals have functional emergency departments with internal protocols dictating the treatment of emergency patients

8.1.1. most emergency departments will stabilize patients to the best of their ability with available equipment and technology before transferring to a more appropriate facility if needed

8.1.2. if a patient wishes to leave the emergency department before appropriate discharge, they are required to sign an AMA form

8.1.2.1. against medical advice

8.2. Hospitals have trauma ratings that help guide ambulances as to where to take emergency patients depending on the severity and type of emergency

8.3. Ambulances communicate with local hospitals via radio to determine which hospital to take them to and prepare the emergency department in advance for the incoming patient and condition

8.4. Paramedics conduct initial examinations to determine severity of emergency and can administer medications and treatments to stabilize patients during the initial hospital transport

8.4.1. e.g. paramedics can administers Narcan to overdose victims to stabilize their condition