Feature Article

Caps on Damamge Awards in Medical Malpractice Cases: Constitutional Challenges

Mark D. Hiatt, MD, MSc, MBA

Capping non-economic damage awards in medical malpractice cases is often proposed as a means to limit the burden of litigation and stem rising health care costs.(1,2) Such caps figure prominently in the current discussion of the so-called Patients' Bill of Rights.(3) Statutory limits on damage awards, however, present a few problems. Their potentially undesirable impact on the incidence of malpractice has been described.(4) In addition, legislative attempts to cap damages must overcome certain legal challenges: limits may restrict the right of access to the courts for redress of injuries and trial by jury under the Seventh Amendment to the United States Constitution and violate the guarantees of due process and equal protection of the laws under the Fourteenth Amendment. Indeed, although case law is divided on the constitutionality of cap legislation, many cases have declared limitations of recovery unconstitutional.* While acknowledging that several other cases have upheld limitations against constitutional challenges, this article focuses on a few of the disapproving judicial responses to damage caps.


Equal Protection


One judicial challenge derives from the "equal protection" clause of the Fourteenth Amendment that forbids any state from denying a citizen equal protection of the laws. In this manner, statutory limits on damage awards single medical malpractice claimants out as a class --- vis-à-vis, for example, plaintiffs in product liability cases --- and hence may be considered discriminatory. In Jones v. State Board of Medicine, Idaho's 1975 Hospital-Medical Liability Act was deemed unconstitutional on these grounds. The Act created a classification that was discriminatory and thus violated the equal protection clause of the Fourteenth Amendment as well as the Idaho constitution. The classification distinguished between those who were damaged as a result of medical malpractice to a degree exceeding the cap and those who were also injured by medical malpractice but whose damages did not exceed the limit. Patients suffering injury exceeding the statutory cap were selectively denied full recovery.

The Idaho court determined that the pivotal point in reviewing the case was whether this classification was invidiously discriminatory so as to warrant prohibition under the guarantees of equal protection. Did a sufficiently compelling cause in promoting the welfare of the public exist to justify the discriminatory classification? Although the Act was deemed a legislative response to Idaho's "crisis" in malpractice insurance, the record did not demonstrate any such crisis, according to the court. Moreover, the court held that no evidentiary basis was presented to support a relationship between the cap created by the Act and attenuation of the alleged crisis.

Another example of judicial objection to the denial of equal protection and due process under federal and state constitutions is Wright v. Central DuPage Hosp. Assn. The plaintiffs argued that by denying recovery for loss and damage in excess of $500,000, the legislature had arbitrarily classified, and unreasonably discriminated against, the most seriously injured victims of medical malpractice. Patients who suffered moderate or minor medical mishaps were not similarly restricted in their actions to recover damages. In particular, the burden of the legislative effort to deal with the alleged medical malpractice crisis fell exclusively on the most severely injured who most needed financial protection.


Right to Trial by Jury and Access to the Courts


Other judicial objections to statutory limits on damage awards claim that they violate the right to trial by jury. In Boyd v. Bulala,** the federal district court ruled that restricting awards in medical malpractice cases in Virginia to $750,000 violated the right to trial by jury provided for by both federal and state constitutions. The assessment of damages, the court determined, was a fact issue reserved for resolution by jury. Further, a cap interfering with jury resolution was an unconstitutional alteration of the jury's role.

A similar verdict of unconstitutionality was reached in Florida. In Smith v. Department of Insurance, the court declared unconstitutional a limit on non-economic damages imposed by the 1986 Tort Reform and Insurance Act. The plaintiffs argued that the Act's $450,000 cap violated a provision of the state constitution that the "courts shall be open to every person for redress of any injury, and justice shall be administered without sale, denial or delay." The court concurred that the cap on non-economic damages interfered with a claimant's access to the courts: the above provision does not contain language that would support the proposition that the right to redress of an injury is limited, or may be limited, to suits above or below any given amount.

Significantly, the Act attempted to abridge a constitutionally protected right without providing any commensurate benefit. The court considered that the only conceivable benefit would be that a patient could enjoy the protection of a cap in the event that a doctor were to file a lawsuit against the patient for some injury inflicted negligently by the patient. Such an occurrence, of course, would be unlikely and hence no real compensatory benefit existed. The legislature thus attempted to abrogate a constitutional right without providing anything of value in return for the loss of the opportunity to recover a larger award.

Nor was it shown that an overpowering public necessity existed to warrant restricting the right of access to the courts for redress of injuries. Although the legislature set forth detailed findings implicating the need for change, the court did not consider these findings sufficiently compelling to warrant abrogating a plaintiff's access to the courts.

Finally, the court determined that Florida's damage cap interfered with the right to trial by jury. If the jury verdict is arbitrarily capped, the plaintiff is not truly receiving the constitutional benefit of trial by a jury uninhibited in its deliberations. If that plaintiff deserves $600,000, as determined by the jury, yet cannot recover more than the arbitrary $450,000, the plaintiff has not received constitutional redress of his injury.

The Florida court maintained a similar position in a prior ruling that has become a seminal decision on the right of access to the courts. In this landmark case, Kluger v. White,*** the court addressed the question of whether the state legislature could restrict the right to redress any injury by establishing a minimum threshold of $550 for economic damages below which the plaintiff would have no right to sue. The legislature attempted to restrict the right of redress at the bottom of the damage spectrum in this case, whereas in Smith v. Department of Insurance it attempted to restrict it at the top.

The court held that a minimum threshold was unconstitutional:

[W]here a right of access to the courts for redress for a particular injury has been provided by statutory law predating the adoption of the Declaration of Rights of the Constitution of the State of Florida, or where such right has become part of the common law of the State pursuant to Fla. Stat. §2.01, F.S.A., the Legislature is without power to abolish such a right without providing a reasonable alternative to protect the rights of the people of the State to redress for injuries, unless the Legislature can show an overpowering public necessity for the abolishment of such right, and no alternative method of meeting such public necessity can be shown.

Apparently, the Florida court considered both minimum thresholds and maximum limits as arbitrary and unnecessary restraints on justice.




Arbitrary statutory caps on damage awards in medical malpractice cases have met with constitutional challenges claiming that such limits restrict the right of access to the courts for redress of injuries, deny equal protection, and violate substantive due process guarantees. Several cases illustrate the dilemma of imposing caps that are meant to reduce the burden of litigation, but may be perceived as conflicting with constitutional principles. Future attempts to legislate limits must take into account these judicial challenges.


* Barbara Moore v. Mobile Infirmary Association, 592 S.2d 156 (Ala. 1991); Brannigan v. Ustilato, 587 A.2d 1232 (N.H. 1991); Morris v. Savoy, 576 N.E.2d 765 (Ohio 1991); Trujillo v. The City of Albuquerque, 798 P.2d 571 (N.M. 1990); Sofie v. Fibreboard, 771 P.2d 711 (Wash. 1989); Condemarin v. University Hospital, University of Utah, 775 P.2d 348 (Utah 1989); Kansas Malpractice Victims Coalition v. Bell, 757 P.2d 251 (Kan. 1988); Lucas v. United States, 757 S.W.2d 687 (Tex. 1988); Smith v. Department of Insurance, 507 So.2d 1080 (Fla. 1987); Baptist Hospital of S.E. Texas v. Barber, 672 S.W.2d 296 (Tex. App. 1984) aff'd 714 S.W.2d 310 (Tex. 1986); White v. State, 661 P.2d 1272 (Mont. 1983) overruled Meech v. Hillhaven West, 776 P.2d 488 (Mont. 1989); Carson v. Maurer, 424 A.2d 825 (N.H. 1980); Arneson v. Olson, 270 N.W.2d 125 (N.D. 1978); Jones v. State Board of Medicine, 555 P.2d 399 (Idaho 1976) cert. denied State Board of Medicine v. Jones, 431 U.S. 914 (1977); Wright v. Central DuPage Hosp. Assn., 347 N.E.2d 736 (Ill. 1976).

** Boyd v. Bulala, 647 F.Supp 781 (W.D.Va. 1986). The court of appeals, however, declared three years later that Virginia's statutory cap on recovery in medical malpractice action violated neither the right of trial by jury since the jury's role does not extend to determining the legal consequences of its factual findings nor the guarantees of due process or equal protection since the cap reasonably related to the valid legislative purpose of maintaining adequate health care services in the Commonwealth. See 877 F.2d 1191 (4th Circuit 1989).

*** Kluger v. White, 281 So.2d 1 (Fla. 1973).





1. Hiatt MD. Reforming the medical malpractice system. Managed Care Medicine 1996;3(6):14-6.
2. Faria MA. Public policy by lawsuits - no one is safe. Medical Sentinel 2000;5(3):88-91.
3. Faria MA. Patients' Bill of Rights in 2002. Medical Sentinel 2002;7(1):8-9.
4. Hiatt MD. Are damage caps the cure for an ailing medical malpractice system? Journal of Managed Care Medicine 1998;2(2):21-3.


Dr. Hiatt is a resident in diagnostic radiology in the University of Virginia Health System in Charlottesville, Virginia. His e-mail address is [email protected].

Originally published in the Medical Sentinel 2002;7(3):86-87. Copyright © 2002 Association of American Physicians and Surgeons (AAPS).