NUMBER 13-10-00392-CV
COURT OF APPEALS
THIRTEENTH DISTRICT OF TEXAS
CORPUS CHRISTI - EDINBURG
TOXICOLOGY ASSOCIATES, INC., Appellant,
v.
SYLVIA AGUIRRE, INDIVIDUALLY AND AS NEXT
FRIEND OF STACY AGUIRRE AND DYLAN AGUIRRE, Appellee.
On appeal from the 117th District Court
of Nueces County, Texas.
MEMORANDUM OPINION
Before Chief Justice Valdez and Justices Rodriguez and Perkes
Memorandum Opinion by Justice Rodriguez
This is an accelerated, interlocutory appeal from the trial court's order denying
appellant Toxicology Associates, Inc.'s motion to dismiss the alleged health-care-liability
claim of appellee Sylvia Aguirre, individually and as next friend of Stacy Aguirre and Dylan
Aguirre, because she failed to file a timely expert report as required by the Texas Medical
Liability Act (TMLA). See TEX. CIV. PRAC. & REM. CODE. ANN. § 74.351(a) (Vernon Supp.
2009) (providing that a plaintiff asserting a "health care liability claim" must serve a
medical expert report upon each party's attorney no later than the 120th day after the date
the original petition was filed). Sylvia responds that she is not required to provide an
expert report because her claim is not a health care liability claim, but instead is based on
Toxicology Associates' breach of chapter 164 of the Texas Health and Safety Code and is
actionable under the Texas Deceptive Trade Practices Act (DTPA).1 See TEX. HEALTH &
SAFETY CODE ANN. §§ 164.010(1), 164.013 (Vernon 2010). By a single issue, Toxicology
Associates contends that Sylvia's health care liability claim must be dismissed because
she failed to file a 120-day expert report. See TEX. CIV. PRAC. & REM. CODE. ANN. §
74.351(a). We reverse the trial court's order, render judgment dismissing Sylvia's claim
against Toxicology Associates, and remand to the trial court for determination of
reasonable attorneys' fees and court costs incurred by Toxicology Associates.
I. BACKGROUND2
Toxicology Associates obtained permits, pursuant to chapter 466 of the Texas
Health and Safety Code, to operate its facilities as narcotic drug treatment programs.
1
Throughout her earlier pleadings, Sylvia referred to her claim as a Texas Deceptive Trade
Practices Act (DTPA) claim. During the motion to dismiss proceedings and now on appeal, Sylvia
describes her claim as a violation of chapter 164 of the Texas Health and Safety Code, which uses the
DTPA as a vehicle for its enforcement. See TEX. HEALTH & SAFETY CODE ANN. § 164.010(1) (explaining
that a person violates chapter 164 if he expressly advertises the services of a treatment facility through the
use of promises or guarantees that cannot be substantiated or that are unsubstantiated claims), § 164.013
(setting out that a person may bring suit under chapter 17 of the Texas Business and Commerce Code for a
violation of chapter 164 and a public or private right or remedy prescribed by subchapter E (Deceptive
Trade Practices and Consumer Protection) of chapter 17 may be used to enforce chapter 64) (Vernon
2010).
2
Because this is a memorandum opinion and the parties are familiar with the facts, we will not
recite them here except as necessary to advise the parties of the Court's decision and the basic reasons for
it. See TEX. R. APP. P. 47.4.
2
See TEX. HEALTH & SAFETY CODE ANN. §§ 466.021-.024 (Vernon 2010); see also TEX. LOC.
GOV'T CODE ANN. § 245.001 (Vernon 2005) (defining "permit" broadly as "a license,
certificate, approval, registration, consent, permit, contract … or other form of
authorization required by law, rule, regulation, or ordinance that a person must obtain to
perform an action or initiate, continue, or complete a project for which the permit is
sought"). From at least March 3, 2007 to May 27, 2008,3 John Aguirre, Sylvia's husband
and Stacy and Dylan's father, received Methadone treatment at certain Toxicology
Associates' locations, one in Corpus Christi, Texas, and another in Houston, Texas, to be
weaned off of prescription medications. According to the medical examiner's report,
John's cause of death on June 30, 2008, was opiate toxicity.
On June 2, 2009, Sylvia notified Toxicology Associates that she was asserting a
claim, which, at the time, she described as a DTPA claim. See TEX. BUS. & COM. CODE
ANN. § 17.505 (Vernon 2002). That same day, Sylvia filed suit against Toxicology
Associates claiming advertising or marketing violations, described as breach of
warranties, and alleging that representations made in its literature wrongly induced John
to use Toxicology Associates' services. Toxicology Associates subsequently filed an
amended answer describing the lawsuit as one "of alleged medical negligence which the
Plaintiffs are attempting to recast as a Deceptive Trade Practices Act case." On
December 15, 2009, Sylvia filed a first amended petition emphasizing the breach of
warranty and DTPA language and removing the word "negligence" from the body of her
petition.
3
Sylvia stated in her affidavit that John received doses of Methadone from Toxicology Associates
at its Corpus Christi, Texas location in 2006.
3
On December 28, 2009, Toxicology Associates filed a motion to dismiss arguing
that Sylvia's claim should be dismissed because no expert report had been filed. The
trial court heard the motion on January 24, 2010, and between January 21, 2010 and
June 24, 2010, a volley of responses and replies were filed, as allowed by the trial court.
On June 24, 2010, the trial court denied Toxicology Associates' motion to dismiss. This
accelerated, interlocutory appeal followed. See TEX. CIV. PRAC. & REM. CODE ANN. §
51.014(a)(9) (Vernon 2008) (permitting appeal of an interlocutory order denying all or part
of a motion to dismiss for failure to file an expert report in a health care liability claim); TEX.
R. APP. P. 28.1(a) (stating that appeals from interlocutory orders are accelerated).
II. STANDARD OF REVIEW
The TMLA requires the dismissal of a suit asserting health care liability claims
against a health care provider if the plaintiff does not timely file an expert report pursuant
to section 74.351(b) of the Texas Civil Practice and Remedies Code. Yamada v. Friend,
No. 08-0262, 2010 Tex. LEXIS 1012, at *8 (Tex. Dec. 17, 2010) (citing TEX. CIV. PRAC. &
REM. CODE ANN. § 74.351). A party may appeal an order that denies all or part of the
relief sought by a 74.351(b) motion. See TEX. CIV. PRAC. & REM. CODE ANN. §§
51.014(a)(9); 74.351(b).
We ordinarily review a trial court's denial of a motion to dismiss for failure to comply
with the expert report requirement for abuse of discretion. See Jernigan v. Langley, 195
S.W.3d 91, 93 (Tex. 2006) (per curiam); Am. Transitional Care Ctrs. v. Palacios, 46
S.W.3d 873, 877 (Tex. 2001). However, "whether a claim is a health care liability claim
pursuant to section 74.351 is a question of law and is reviewed de novo." Christus
Spohn Health Sys. Corp. v. Sanchez, 299 S.W.3d 868, 873 (Tex. App.–Corpus Christi
4
2009, pet. denied) (citing Valley Baptist Med. Ctr. v. Stradley, 210 S.W.3d 770, 773 (Tex.
App.–Corpus Christi 2006, pet. denied)).
III. DISCUSSION
Toxicology Associates contends generally that dismissal is mandated because
Sylvia asserted a health care liability claim and failed to file a 120-day expert report.
More specifically, Toxicology Associates argues that Sylvia's claims are health care
liability claims because (1) Toxicology Associates is a health care provider, and (2) the
nature of her claim concerns the care and treatment rendered to John for narcotic
dependency.
A. HEALTH CARE PROVIDER
Toxicology Associates first asserts that this claim has been brought against it as a
health care provider. A "health care liability claim" is a cause of action against a health
care provider for "treatment, lack of treatment, or other claimed departure from accepted
standards of medical care or health care or safety which proximately results in injury to or
death of the patient, whether the patient's claim or cause of action sounds in tort or
contract." TEX. CIV. PRAC. & REM. CODE ANN. § 74.001(a)(13) (Vernon 2005). The
TMLA provides that a health care provider is "any person, … corporation, facility or
institution duly licensed, certified, registered or chartered by the State of Texas to provide
health care.…" Id. § 74.001(a)(12)(A) (Vernon 2005). "Health care" is defined as "any
act or treatment performed or furnished, or which should have been performed or
furnished, by any health care provider for, to, or on behalf of a patient during the patient's
medical care, treatment, or confinement." Id. § 74.001(a)(10) (Vernon 2005).
5
In this case, each Toxicology Associates facility obtained a permit to treat narcotic
addiction. See TEX. HEALTH & SAFETY CODE ANN. § 466.024. Under section 466, a
"facility" is defined, in relevant part, as "an outpatient clinic" and "any other location in
which a structured narcotic dependency program is conducted." Id. § 466.002(6)
(Vernon 2010). In addition, "[t]reatment of narcotic addiction by permitted treatment
programs is recognized as a specialty chemical dependency treatment area using the
medical model." Id. § 466.001(b) (Vernon 2010).
Toxicology Associates asserts that it is a health care provider—treating narcotic
addiction through the use of "the medical model." See id. It argues that the permit
obtained by each facility evidences the fact that Toxicology Associates is engaged in the
treatment of patients and that it provides health care to its patients, one of whom was
John Aguirre. It also asserts that it is a health care provider as evidenced by the records
it produced in this case, records which show John was seen by physicians, counselors,
and nurses at Toxicology Associates' clinics and which it identifies as John's medical
records. And, the Houston Court of Appeals has held that an inpatient drug and alcohol
treatment center licensed under chapter 464 of the health and safety code is a health care
provider for the purposes of chapter 74. See Christus Health v. Beal, 240 S.W.3d 282,
287 (Tex. App.–Houston [1st Dist.] 2007, no pet.).
We find Toxicology Associates' arguments and the guidance provided by Christus
Health persuasive. However, we need not reach its health-care-provider argument
because Sylvia does not dispute Toxicology Associates' status as a health care provider
for the purposes of asserting a health care liability claim in this case and did not do so in
the trial court. Rather, on appeal, Sylvia responds only that Toxicology Associates is a
6
chemical dependency facility as prescribed by section 462.001 of the health and safety
code and, as such, is subject to section 164.010's marketing provisions and any violations
thereof. See TEX. HEALTH & SAFETY CODE ANN. § 164.010; id. § 462.001 (Vernon 2010).
Sylvia does not challenge Toxicology Associates' position that John was provided
treatment by health care providers at its clinics or that the facility is a health care provider.
Therefore, on this record, we treat Toxicology Associates, a facility permitted under
chapter 466, as a health care provider. See id. §§ 466.021-.024; TEX. CIV. PRAC. & REM.
CODE ANN. § 74.001(a)(12)(A).
B. NATURE OF THE CLAIM
Toxicology Associates also argues that Sylvia's claim is a health care liability claim
because the nature of her claim concerns the care and treatment rendered to John. We
agree.
A claim is a health care liability claim governed by chapter 74 if it alleges a breach
of accepted standards of health care or if the claim is inseparable from the rendition of
health care. Marks v. St. Luke's Episcopal Hosp., 319 S.W.3d 658, 664 (Tex. 2010)
(plurality op.); Diversicare Gen. Partner, Inc. v. Rubio, 185 S.W.3d 842, 848 (Tex. 2005);
see, e.g., Earle v. Ratliff, 998 S.W.2d 882, 885, 893 (Tex. 1999) (setting out that a
surgeon's statements that a patient needed surgery, would get "95% better" and able to
return to work, and that devices being implanted were safe and permanent could not be
brought under the DTPA, but were medical negligence claims); MacGregor Med. Ass'n v.
Campbell, 985 S.W.2d 38, 40-41 (Tex. 1998) (per curiam) (holding that a provider's
failure to advise a patient of possible complications in his condition and a
misrepresentation that the patient "was medically fine" indicated a cause of action for
7
medical malpractice); Gormley v. Stover, 907 S.W.2d 448, 449-50 (Tex. 1995) (per
curiam) (concluding that representations that a surgeon "could perform the surgery with
no problems, that a skin graft would work as well as a bone graft, that [the patient's
dentures] would fit well and . . . she would have no problems wearing [them]" all had to do
with whether surgeon's selection of surgical procedure and performance of it met
standard of care for dentists in such circumstances); Walden v. Jeffery, 907 S.W.2d 446,
448 (Tex. 1995) (per curiam) (deciding that the marketing of dentures was inseparable
from the profession of dentistry and the medical services provided and, therefore, was "an
inseparable part of [the defendant's] rendition of medical services"; thus, the plaintiff's
claim was a health care liability claim subject to the requirements of chapter 74).
"Whether a claim is a health care liability claim depends on the underlying nature
of the claim being made." Yamada, 2010 Tex. LEXIS 1012, at *9 (citing Garland Cmty.
Hosp. v. Rose, 156 S.W.3d 541, 543 (Tex. 2004)). In determining a claim's underlying
nature, we consider the duties allegedly breached as well as the alleged wrongful
conduct, see Rubio, 185 S.W.3d at 851, looking to the factual allegations to determine the
gravamen of the complaint and not being bound by the form of the pleading or how
complaints are labeled. See id; Sci. Image Ctr. Mgmt. v. Brewer, 282 S.W.3d 233,
237-38 (Tex. App.–Dallas 2009, pet. denied) ("The Texas Supreme Court repeatedly has
held that plaintiffs cannot, through artful pleading, avoid the strictures … [of] chapter 74
by recasting health care liability claims as other causes of action[,]" however, while not
being "bound by Brewer's pleadings, a review of her allegations [in her statement of facts
on appeal] is helpful in evaluating whether her allegations … are health care liability
claims recast as a DTPA action.") (citations omitted); see also Yamada, 2010 Tex. LEXIS
8
1012, at *2, 13 (concluding that claims against a health care provider based on one set of
underlying facts cannot be brought as both health care liability claims subject to the TMLA
and ordinary negligence claims not subject to the TMLA because the TMLA and its
procedures and limitations would be effectively negated); but see Sorokolit v. Rhodes,
889 S.W.2d 239, 242-43 (Tex. 1994) (concluding that a physician's explicit promise that
his patient's appearance following cosmetic surgery would be identical to a specific
magazine photograph of a nude model did not involve negligence and was, therefore,
actionable under the DTPA).
In her petition, Sylvia claimed that the following statements found in Toxicology
Associates' literature induced John to use the services of the facility: (1) "Methadone
taken under a doctor's care causes no harm to any of your body organs and does not
change your ability to think clearly"; (2) "Properly prescribed Methadone is not intoxicating
and does not create euphoria, sedation[,] or an analgesic effect"; and (3) "Methadone is
medically safe." She further asserted that these alleged warranties were breached
because "none of the results guaranteed were delivered. The results guaranteed in
[Toxicology Associates'] literature did not occur." In addition, Sylvia asserted that
Toxicology Associates "wrongfully disseminat[ed] information concerning the toxicity of
Methadone," and "wrongfully advis[ed] the Deceased concerning the use of
Methadone."4 Sylvia asserted that these allegedly unlawful acts and practices were a
producing cause of damages and, without identifying specific damages, claimed that the
4
In her original petition, Sylvia claimed that Toxicology Associates was negligent when it
"wrongfully disseminat[ed] information concerning the toxicity of Methadone," and "wrongfully advis[ed
John] concerning the use of Methadone." In her amended petition, she asserted that these acts violated
the DTPA.
9
suit was to recover the amount of money which would fairly and reasonably compensate
her for those damages.
In her pleadings, Sylvia also asserted, however, that John's cause of death was
"Opiate (Methadone) Toxicity"5 and claimed the following:
On multiple occasions, as shown in [Toxicology Associates'] internal
records, [John] stated to [Toxicology Associates] that he was not living a
healthier and better life as was guaranteed. His ability to think clearly was
also impared [sic] and he did feel "high" or "drugged." At one point
[Toxicology Associates] was forced to call 911 to transport John … to the
hospital due to his "drugged" state.
According to her petition, John asked to be "'weaned off' of [M]ethadone in order to
function in his day to day life," which "had gotten worse, not better since being on
[Toxicology Associates'] [M]ethadone." Sylvia claimed, in her petition, that Toxicology
Associates again "warranted to John … 'Methadone taken under a doctor's care causes
no harm to any of your body organs and does not change your ability to think clearly.'"
Sylvia alleged that Toxicology Associates "never decreased his dosage in the face of
failed guarantees, but rather, continued with the same 190 milligram dosage, daily until"
his death. She also asserted that Mr. Aguirre's "death resulted form [sic] the Defendants
willful act or omission, which intitles [sic] [him] to exemplary damages."
In addition to the above-mentioned pleadings, Sylvia's attorney sent a notice letter
to Toxicology Associates. The letter appears in the record as an exhibit to one of
Sylvia's responses to Toxicology Associates' motion to dismiss. While referencing
statements made in the literature and their inducement effect, the following portions of the
letter referring to Toxicology Associates' negligence are also helpful in our evaluation:
5
Sylvia's original petition set out that "[t]he cause of death was [o]piate [t]oxicity, completely
attributable to the build up [sic] of Methadone in [John's] system."
10
Please be advised that we represent the widow and children of John
Aguirre. Mr. Aguirre was a patient at your clinic. He was in treatment at
your establishment for two years.…
After consulting Mr. Aguirre's medical records as provided by your
clinic, he exhibited all the intoxicating effects previously mentioned.… [U]p
until his time of death he was administered 190 milligrams of Methadone
daily, with complete disregard to his symptoms [and his request to be
weaned off of Methadone].
Mr. Aguirre died as a result of the "care" provided by your clinic. His
cause of death was Opiate Toxicity. The only Opiate in his system at the
time was Methadone as provided by your clinic, under your care.… As you
can imagine, the damages caused by your actions are immense. Please
present this letter to your insurance carrier. If you do not have insurance
please contact our offices that we may address this matter, and make whole
Mr. Aguirre's widow and children. This letter is sent in adherence to the
Texas Deceptive Trade Practices Act.
Furthermore, it was not until Sylvia filed her response to Toxicology Associates'
motion to dismiss that she asserted the claim that she now argues on appeal: that
Toxicology Associates violated chapter 164 through its misleading marketing practices.
See TEX. HEALTH & SAFETY CODE ANN. § 164.010(1). On appeal, Sylvia argues that her
claim against Toxicology Associates is for its violation of the Treatment Facilities
Marketing and Admission Practices Act found in chapter 164 of the health and safety
code, a claim that can be brought through the DTPA.6 See id. §§ 164.010(1), 164.013.
Sylvia specifically refers us to section 164.010 which provides, in relevant part, the
following: "It is a violation of this chapter, in connection with the marketing of mental
health services, for a person to: (1) advertise, expressly or impliedly, the services of a
treatment facility through the use of (A) promises of cure or guarantees of treatment
results that cannot be substantiated; or (B) any unsubstantiated claims .…" Id. §
6
Also, in response to Toxicology Associates' motion to dismiss, Sylvia asserted that Toxicology
Associates failed to disclose material facts concerning John's purchase of a product and that Toxicology
Associates' "brochure does not state that Methadone itself is addictive."
11
164.010(1). This language, however, is absent from her petition. Rather, the factual
allegations in Sylvia's petition involve "undelivered" DTPA warranties that allegedly
induced John to use services provided by Toxicology Associates and the wrongful
dissemination of information and wrongful advice given by Toxicology Associates
concerning the toxicity of Methadone.
Nonetheless, Sylvia now argues that the alleged breach was not in the standard of
care provided by Toxicology Associates, but in its marketing practices. See id. Sylvia
contends that the duties imposed in chapter 164 are not related to the care provided to
each patient, but to the marketing and advertising used to induce consumers to utilize its
services. We agree that, given certain factual allegations, a party's claim that a mental
health facility and a chemical dependency treatment facility violated section 164 of the
health and safety code could survive. See id. § 164.002 (Vernon 2010) ("The purpose of
this chapter is to safeguard the public against fraud, deceit, and misleading marketing
practices and to foster and encourage competition and fair dealing by mental health
facilities and chemical dependency treatment facilities by prohibiting or restricting
practices by which the public has been injured in connection with the marketing and
advertising of mental health services and the admission of patients."). However, we do
not agree that the facts and claims alleged in this case support such a cause of action.
The basis for Sylvia's claim lies in her allegations of negligence by Toxicology
Associates, negligence in the care and advice provided to John as part of his treatment at
its clinics in Houston and Corpus Christi. In her notice letter, Sylvia acknowledged that
John died as a result of the "care" provided at Toxicology Associates' clinic. Sylvia sets
out in her petition, as well as in other documents, that the personnel at the facilities failed
12
to listen to John when he complained about not living a healthier and better life and about
feeling "high" or "drugged" while on Methadone and asked to be weaned off of
Methadone. Sylvia alleges that Toxicology Associates "never decreased his dosage in
the face of failed guarantees, but rather, continued with the same 190 milligram dosage,
daily until" his death. And it is undisputed that the cause of death was opiate toxicity.
These allegations and undisputed facts support a claim that John's death arose out of the
allegedly wrongful manner in which Toxicology Associates conducted John's Methadone
treatment.
Moreover, although the complained-of statements in the literature may have
induced John to participate in Toxicology Associates' Methadone treatment program,
Sylvia's allegations do not concern damages caused by Toxicology Associates' marketing
practices that allegedly made unsubstantiated claims through its literature. Sylvia cites
no damages related to her marketing-violation claim, such as the cost of John's
treatment. Rather, her allegations concern damages allegedly caused by Toxicology
Associates' negligent treatment of John's prescription drug addiction. This is supported
by her comment in the notice letter that the damages caused by Toxicology Associates'
actions are "immense."
Sylvia's claim derives from Toxicology Associates' alleged negligent actions that
were inextricably related to its professional duty of treating John's drug addiction with
Methadone, a claim that is inseparable from the rendition of health care. See Marks, 319
S.W.3d at 664. The claim also derives from Toxicology Associates' alleged breach of
accepted standards of health care. See id. Regardless of what Sylvia would like this
case to be, it is a claim that the treatment facility departed from an accepted health care
13
standard. Sylvia's claim is dependent on a finding of negligence against Toxicology
Associates—a determination of whether Toxicology Associates, through its counselors,
nurses, or physicians, failed to meet the required standard of health care. Therefore, in
our de novo review, we conclude that the essence of Sylvia's claims is that Toxicology
Associates committed medical negligence, and Sylvia may not recast her claims as
violations of chapter 164 in an attempt to avoid the requirements of chapter 74.
Because it is undisputed that Toxicology Associates is a health care provider and
we have concluded that the nature of Sylvia's claim concerns the care and treatment
Toxicology Associates rendered to John, her failure to file a 120-day expert report as
required by the TMLA mandates dismissal. See TEX. CIV. PRAC. & REM. CODE ANN. §
74.351. We sustain Toxicology Associates' sole issue.7
IV. CONCLUSION
Accordingly, we reverse the trial court's order denying Toxicology Associates'
motion to dismiss, render judgment dismissing Sylvia's claims against Toxicology
Associates with prejudice, and remand to the trial court for determination of reasonable
attorneys' fees and costs of court incurred by Toxicology Associates.
NELDA V. RODRIGUEZ
Justice
Delivered and filed the 31st
day of January, 2011.
7
By a second sub-issue, Toxicology Associates argues that Sylvia's claims cannot be asserted
under the DTPA because (1) the TMLA prohibits DTPA claims against health care providers and (2) the
DTPA itself excludes a lawsuit of this nature—a lawsuit involving personal injury, survival, and wrongful
death claims. Having concluded that Sylvia's claims are health-care-liability claims and subject to chapter
74, we need not address Toxicology Associates' remaining sub-issue as it is not dispositive of this appeal.
See TEX. R. APP. P. 47.1.
14