## Facts

- Lawrence Fein, a Kaiser subscriber, repeatedly sought care from physicians affiliated with Permanente Medical Group for chest pain.
- At an office visit, a nurse practitioner examined Fein, consulted a supervising physician, diagnosed muscle spasm, and prescribed Valium.
- On a later emergency-room visit, a physician again diagnosed muscle spasm after a chest x-ray and discharged Fein.
- On a subsequent emergency-room visit, another physician ordered an EKG that showed a myocardial infarction; Fein was admitted and treated.
- Fein sued for negligent failure to timely diagnose and treat his heart condition, claiming earlier diagnosis and treatment would have prevented the heart attack or reduced residual harm.
- Fein’s expert testified that an EKG should have been ordered earlier and that the delay reduced Fein’s life expectancy; defense experts disputed breach and causation.
- The jury returned a verdict for Fein totaling about $1.29 million, including $500,000 in noneconomic damages.
- The trial court reduced noneconomic damages to $250,000 under Civil Code § 3333.2 and entered judgment of roughly $1 million, applying MICRA’s collateral-source provisions under Civil Code § 3333.1.

## Issues

1. Whether the trial court committed reversible error by excusing for cause all prospective jurors who were Kaiser members and by giving challenged liability and damages instructions.
2. Whether MICRA’s medical-malpractice reforms are unconstitutional, including:
   1. Whether Civil Code § 3333.2’s $250,000 cap on noneconomic damages violates due process, equal protection, the right to jury trial, or separation of powers.
   2. Whether Civil Code § 3333.1’s modification of the collateral source rule violates due process or equal protection.
3. Whether the trial court was required to order periodic payments of future damages under MICRA’s periodic-payment provisions.

## Decision

- The California Supreme Court largely affirmed the judgment for Fein as modified by MICRA.
- The court held there was no reversible error in the Kaiser-member for-cause exclusions; any error was not shown to be prejudicial.
- The court held challenged instructions, including an overbroad instruction suggesting a nurse practitioner was held to the same standard of care as a physician, did not warrant reversal because any error was harmless on this record.
- The court upheld Civil Code § 3333.2 as constitutional and sustained the trial court’s reduction of noneconomic damages to $250,000.
- The court upheld Civil Code § 3333.1 as constitutional.
- On periodic payments, the court found no reversible error in the trial court’s failure to order periodic payment of future damages on the record presented.

## Legal Principles

- A judgment will not be reversed for nonstructural trial error in jury selection or instructions absent a showing of prejudice; trial courts have broad discretion in managing voir dire.
- The Legislature may define and limit tort damages; a damages limitation satisfies substantive due process if it is rationally related to a legitimate state interest.
- Civil Code § 3333.2’s cap on noneconomic damages in medical malpractice cases is subject to rational-basis review and does not violate equal protection where neither a suspect class nor a fundamental right is implicated.
- Statutory limits on the enforceable amount of damages do not, by themselves, violate the right to jury trial when the jury still performs its factfinding role and the statute limits the legal effect of the award.
- Civil Code § 3333.1’s collateral-source modification in medical malpractice cases survives rational-basis review as a legislative response to concerns about malpractice insurance costs and health-care affordability.

## Conclusion

The court affirmed a medical-malpractice verdict while enforcing MICRA’s $250,000 noneconomic-damages cap and collateral-source rule changes, holding these reforms constitutional and reiterating that alleged errors in jury selection and instructions warrant reversal only when they are shown to have affected the outcome.


Fein v. Permanente Med. Grp., 695 P.2d 665 (Cal. 1985)