Simms Ex Rel. C.J. v. United States
2016 U.S. App. LEXIS 18267
| 4th Cir. | 2016Background
- Misty Simms sued the United States under the FTCA for wrongful birth after a federally supported clinic (Valley Health) failed to timely inform her of fetal abnormalities detected at 18 weeks, preventing lawful termination; her son C.J. was born with severe impairments.
- The district court found the United States liable and awarded Simms $12,222,743: past medical expenses, future medical expenses (present value over 21 years), lost income, and noneconomic damages; C.J.’s claim was dismissed and he is not a plaintiff for recovery purposes.
- C.J.’s extraordinary medical care to date has been paid by West Virginia’s Medicaid and Medicaid Waiver programs.
- The government appealed only the damages awards related to past and future medical expenses and sought a reduction under West Virginia law/statute; it also challenged the district court’s refusal to create a reversionary trust.
- The Fourth Circuit affirmed liability and several damage components, held that billed amounts (not Medicaid payments) may be used to measure reasonable medical-value damages under West Virginia law, but vacated and remanded the award for past and future medical expenses for a post‑verdict collateral‑source hearing under West Virginia’s Medical Professional Liability Act.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Recoverability of past medical expenses when Medicaid paid them | Simms: wrongful birth damages include extraordinary medical costs incurred or legally owed by parents; Medicaid payment does not bar recovery | U.S.: no out‑of‑pocket loss, so plaintiff cannot recover medical expenses paid by Medicaid | Held: Simms may recover; West Virginia collateral‑source rule allows recovery despite Medicaid payments (parents’ support duty and collateral‑source rule protect benefits) |
| Measure of past medical damages: billed amount vs. Medicaid paid amount | Simms: use providers’ billed charges as prima facie evidence of reasonable value (Kenney) | U.S.: should use the amount actually paid by Medicaid because providers must accept Medicaid rates | Held: Use billed amounts; Kenney protects billed/charged amounts from reduction regardless of private or public payer discounts |
| Applicability of W. Va. Medical Professional Liability Act (collateral-source reduction) and Medicaid subrogation | Simms: argued Medicaid has subrogation/lien that may preclude reduction; factual record unclear | U.S.: statute permits post‑verdict hearing and possible reduction; Simms isn’t the Medicaid “recipient,” so subrogation under state statute may not apply | Held: Vacated and remanded for a post‑verdict collateral‑source hearing under W. Va. Code § 55‑7B‑9a to decide subrogation, rights to recovery, and whether future collateral benefits will be paid with reasonable certainty |
| Reversionary trust for future medical expenses | Simms: sought creation of a reversionary trust to preserve funds for C.J.’s care | U.S.: contested the damages and appropriate form of relief | Held: Fourth Circuit did not decide in light of remand; district court may reconsider ordering a reversionary trust on remand if appropriate |
Key Cases Cited
- James G. v. Caserta, 332 S.E.2d 872 (W. Va. 1985) (recognizing wrongful birth claim and recoverability of extraordinary child‑rearing costs)
- Kenney v. Liston, 760 S.E.2d 434 (W. Va. 2014) (collateral‑source rule protects billed medical charges from offsets due to payer discounts)
- Jordan v. Bero, 210 S.E.2d 618 (W. Va. 1974) (proper measure of medical‑expense damages is reasonable value of services)
- Delong v. Kermit Lumber & Pressure Treating Co., 332 S.E.2d 256 (W. Va. 1985) (measuring future medical expenses by reasonable value)
- Ilosky v. Michelin Tire Corp., 307 S.E.2d 603 (W. Va. 1983) (purpose of collateral‑source doctrine to prevent reduction of defendant’s liability)
- Packard v. Perry, 655 S.E.2d 548 (W. Va. 2007) (parents’ duty to support child and pay for medical expenses)
- Am. Foreign Serv. Ass’n v. Garfinkel, 490 U.S. 153 (1989) (leave unresolved statutory interpretation questions to the district court on remand)