Paula goes to see her primary care physician, Dr. Snead, because of some heart palpitations and shortness of breath. Dr. Snead performs an EKG, which reads normal, and obtains some information about the symptoms. Dr. Snead recommends that Paula undergo an exercise stress test with imaging so that a cardiologist can take a closer look at Paula's heart while she exercises. She also recommends that Paula stop smoking, start exercising, and lose roughly 35 pounds through diet change and exercise over the next year.

Assume that generally a regular stress test would be performed instead of an imaging stress test. The imaging stress test helps to visually detect abnormalities in the heart. It is more time consuming and expensive. It is generally recommended if a patient has a prior history of heart issues or has chest pain that comes on suddenly after physical effort and goes away with rest. It is also generally only recommended for women over the age of 50.

Paula is 39 years old. She does not have a prior history of heart problems, and her palpitations did not come on suddenly after physical effort. However, there are no readily apparent reasons for the palpitations, such as medications or any recent health changes, and Paula has a history of heart disease in her family. Her father died as a result of a heart attack when he was 48 years old, and his father died of heart failure when he was 52 after several heart attacks. As a result, Dr. Snead felt that it would be a good idea to have the imaging done, just to be safe, and to get a baseline of images in case Paula has future problems.

Paula's managed care organization (MCO) denies coverage for the imaging stress test. The MCO provides her the right to an internal appeal as required by law. Paula contacts Dr. Snead to ask about her options. Dr. Snead says that an internal appeal with likely not be successful, so she does not want to allocate the time to provide information to the MCO for an appeal. She schedules Paula for a regular stress test instead, and it is approved by the MCO.

Paula has the regular stress test, and it does not reveal anything abnormal. She does not stop smoking. She tries to exercise and change her diet, but when she does not lose any weight after a couple of weeks, she reverts back to her old diet and sedentary ways.

One month after the stress test, Paula has a heart attack when walking up the stairs at work. EMTs arrive quickly and get Paula to the emergency room at Health Care Central, a nonprofit hospital. Paula survives the heart attack and is referred to the coronary care unit at the hospital. Through a series of miscommunications between the health care providers in the unit, several standard post-heart attack tests are not performed, and Paula is released 3 days after her heart attack. Two weeks later, Paula has another heart attack while at home doing some light yard work. There is no one there to help her or to call for help. The attack leads to cardiac arrest, and she dies.

1. What are the potential claims and who are the potential defendants?
2. What are the legal standards for the potential claims and what evidence would the plaintiff need to present to prevail on the claims?
3. Will the plaintiff need expert testimony? If so, what would the testimony need to establish?
4. What are the defendant's best defenses and best arguments against liability based upon the facts?