Carroll v. Konits
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Carroll v. K onits, No. 117, September Term, 2006 HEADNOTE: In accorda nce with th e Health Care Malpractice Claims Statute, Maryland Code (1974, 2002 Repl. Vol., 2006 Cum. Supp.), § 3-2A-04(b) of th e Courts and Judicial Proceedings Article, a certificate of qualified expert must contain the name of the licensed professional about whom the qualified expert is speaking, a statement that the named professional breached the standard of care, and tha t the departure from the stan dard of care was the proxim ate cause o f the pla intiff s in juries. The court is required to dismiss the claim, withou t prejud ice, wh en the d ocum entation fails to sa tisfy these stated re quirem ents. In the Circuit C ourt for Ba ltimore City No. 24-C-05-011066 IN THE COURT OF APPEALS OF MARYLAND No. 117 September Term, 2006 ____________________________________ MARY CARROLL v. PHILLIP H. KONITS, M.D. ET AL. ___________________________________ Bell C.J. Raker Cathell Harrell Battaglia Greene Wilne r, Alan M . (Retired, specially assigned), JJ. ____________________________________ Opinion by Cathell, J. which Harrell, J., concurs. Bell, C.J. and Greene, J ., dissent. ____________________________________ Filed: July 27, 2007 This matter arises from a medical malpractice claim filed b y Mary Carro ll, appellant, against Dr. Phillip H. Konits and Dr. Efem E. Imoke, appellees. C arroll, in accord ance with applicable law, initially filed he r complain t with the H ealth Care Alternative Dispute Resolution Office (the H CADR O ). 1 Thereaf ter, the claim w as transferre d to the Circ uit Court for Baltim ore City. The C ircuit Court d ismissed the case on various grounds, including, but not limited to, Carroll s failure to subm it a proper certificate of qualified expert ( Certificate )2 as required by the Health Care Malpractice Claims Statute (the Statute ), Maryland C ode (197 4, 2002 R epl. Vol., 2006 Cum . Supp.), § 3-2A-04(b) of the Courts and Judicial Proceedings Article. Carroll filed a timely appeal to the Court of Special Appeals. On January 2, 2007, while the appeal was pending in the intermediate appellate court, this Court issued a writ of certiorari on its own motion to review the following question: Did the Circuit Court err in finding that Mary Carroll s expert witness report and certification was legally insufficient, thereby dismissing the case? Carroll v. K onits, 396 Md. 524 , 914 A.2d 768 (2007). We hold that a Certificate is a condition precedent and, at a minimum, must identify 1 Prior to January 11, 2005, this office was known as the Health Claims Arbitration Office. Maryland Code (1974, 2006 Repl. Vol.), § 3-2A-03 of the Courts and Judicial Proceedings Article (describing in the Editor s note when the name change was made by the General Assembly and when it was to take effect). We refer to the office by its current name throughout this opinion. 2 Various sources use different language to refer to the document that is to be filed with a com plaint alle ging m alpractic e. The relevant statute uses certificate of qualified expert. Other sources use Certificate of Merit in reference to the same document. We use Certificate herein. with specifi city, the defendant(s) (licensed professional(s)) against wh om the claims are brought, include a statement that the defendant(s) breached the applicable standard of care, and that such a departure from the standard of care was the proximate cause of the plaintiff s injuries. In the case sub judice, the certificate w as incomp lete becaus e it failed to spe cifically identify the licensed profession als who a llegedly breach ed the stand ard of care and failed to state that the alleged departure from the standa rd of care, by whicheve r doctor the expert failed to iden tify, was the proximate cause of Carroll s injuries. Therefore, because the Certificate is a condition precedent, the Circuit Court for Baltimore City correctly granted the appellees m otion to dismiss the case and, accordingly, we affirm the judgment of the Circ uit C ourt for B altim ore C ity. I. Factual and Procedural Background On Septemb er 19, 2001 , Dr. Imok e perform ed a unilateral mastectomy of Carro ll s left breast. As a part of the procedure, Dr. Imoke left a catheter3 inside Carroll s chest so that 3 Acc ording to Tab er s C yclop edic Medica l Dic tionary, 1734 (20th ed. 2005), po rta means: The point of en try of nerves and vessels into an organ or part. A catheter is: A tube passed into the body for evacuating fluids or injecting them into body cavities. It may be made of elastic, elastic w eb, rubber, g lass, metal, or plastic . Id. at 357. To the nonmedical mind, the combination of these words may be somewhat confusin g with resp ect to the present context. Apparently, however, the combination of these terms, in reference to the proc edure at i ssue , is sta ndard pr actic e in th e me dica l com mun ity. An information sheet provided to patients by the Duke Comprehensive Cancer Center (which has no involvemen t in the present case), better explains the m eaning of the term and the operation of the device: [I]mplanted port for central venous access (po rta-cath) allow [ing] a nur se to inject or infuse medication into a long term catheter w hich has b een placed in a vein in the upper chest (just below the collar bone). The catheter may stay (contin ued...) -2- chemotherapy could b e adm inistered . Carroll claims that she wa s not aware that the catheter was inserted at the time that it occurred. The catheter was supposed to be remo ved within two months after Carroll completed chemotherapy. Dr. Imoke, however, did not make a follow-up appointment to remove the catheter. Instead , he relied on Dr. Kon its, Carroll s oncolog ist, to info rm him th at Ca rroll had com plete d chemo therapy. She complete d chemo therapy on A pril 11, 2002. The catheter was not removed, however, until March 25, 2003 tw o and on e-half years af ter it was initially inserte d. Carroll asserts that she suf fered pain and discomfort, a deep vein thrombosis, and chronic venous stasis of the right arm with chronic lymph edema due to the catheter being left inside her chest for a prolonged period of time. On March 25, 2005, Carroll filed a complaint with the HCADRO . She alleged that Drs. Konits and Imoke were negligent in failing to communicate the need to have the catheter removed in a timely manner. Approximately four months later, on Augus t 4, 2005, C arroll filed a letter signed by Dr. Wanda J. Simmons-Clemmons, which purported to be a 3 (...continued) in place for weeks or months. This makes it un necessary fo r the patient to need an IV started every time it is necessary to give medication into a vein. The catheter also makes it possible for blood to be drawn from the catheter and not through vein sticks. . . . A doctor would o rder a porta-cath inserted for patients who will require medications to be given into a vein many times over weeks or months [e.g. a patient undergoin g chemotherapy]. It also makes frequent blood draws for blood tests easier since the blood can be taken f rom the cathete r. See http://cancer.duke.edu/pated/Materials/Procedures/ ImplantablePortInsertionCare.pdf, last visite d on Ju ne 25, 2 007. Hereinafter we will use the term cathete r to refer to the device inse rted into Ca rroll. -3- Certificate. Dr. Simmons -Clemm ons sum marized a timeline of C arroll s med ical treatmen ts and then wrote: In my professional opinion, there was no clear communication to the patient that indicated she should seek medical attention in the removal of the catheter from her chest after chemotherapy was comp leted. If this was done, it was not documented. Secondly, there was mention made of an approximate time chemo should be completed by Dr. Konits in his consult dated January 31, 2002. The note was signed off by Dr. Ohio; however, there was mention of completion of chem o in multiple subsequent office visits. Also, the patient was to follow-u p with Dr. Imoke in September 2002. Again, no mention was made that the patient should call sooner if and when chemo ended. Neither was the patient recalled for her September 2002 followup. If this was done I do not have a copy of the documentation of it. Thirdly, it does appear that Mrs. Mary Carroll suffered complications arising from having a catheter in place for too long[,] i.e. A DVT and chronic venous stasis of the right arm with ch ronic lym phede ma. On October 3, 2005, afte r more than 180 days had elapse d from the time that Ca rroll initially filed her co mplaint, 4 Drs. Ko nits and Im oke filed a motion to d ismiss the claim with 4 Maryland Code (1974, 2002 Repl. Vol., 2006 Cum. Supp.), § 3-2A-04(b)(1)(i) of the Courts and Judicial Proceedings Article, allows a claimants a period of 90 days, from the initial filing of the c omplaint, to f ile the Certificate. Section 3-2 A-04(b) (1)(ii) provide s that: In lieu of dismissing the claim or action, the panel cha irman or the court shall grant an extension of no more than 90 days for filing the certificate required by this paragraph, if: 1. The limitations period applicable to the claim or action has expired; and 2. The failure to file the certific ate was n either willfu l nor the resu lt of gro ss neglig ence. Thus, the time period in which Carroll must have filed her certificate is 180 days from the filing of her in itial com plaint. See also McCready Memorial Hosp. v. Hauser, 330 Md. 497, 508, 624 A.2d 1249, 1255 (1993) (concluding that the 90-day extension commences, (contin ued...) -4- the HCADRO on the basis that Dr. Simmons-Clemmons s documentation was deficient under the requirements set forth in § 3-2A-04(b) of the Courts and Judicial Proceedings Article. Drs. Ko nits and Im oke claim ed that Ca rroll failed to file a Certificate and that she merely tendered an informal, unswo rn letter. On O ctober 5, 20 05, Carroll re quested tha t, in the interest o f justice [,] the Director grant her an additional 60 days to correct the deficiencies in the document filed.5 The Director acting, in the interest of justice, granted Carroll s request for additional time, giving her until December 1, 2005, to correct the deficiencies. On October 28, 2005, Carroll submitted an amended certification in an attempt to cure the defects in the original submission. The certificate again contained a summary of Carroll s medical v isits and treatm ents and included the same language quoted supra, except that Dr. Simmons-Clemmons altered the language from it does appear that Mrs. M ary Carroll suffered comp lications arising from having a catheter in place for too long to having a catheter in place for longer than what is standard treatment[.] (Emphasis add ed). Additionally, a new paragraph was added to the second letter that stated: 4 (...continued) without the necessity of a request, upo n the expira tion of the in itial 90-day period and is only available where the expert s certificate is filed w ithin the 90-day e xtensio n perio d, i.e., within 180 days of filing the initial complaint. ) We note that in o rder to gran t an extensio n the plain language of the statute requires that both the statu te of limitation s has expire d and that th e failure to file the certificate was neither willful nor the result of gross negligence. The issue of whether the initial 90 day extension was proper is not before this Court and we do not resolve it. For a discussion of when the granting of 90 day extension is appropriate see McCready, supra. 5 This extension occurred when there was nothing to extend. The original 90 + 90, i.e., 180 day period had already expired. -5- It is my professional opinion that M rs. Carroll sustained injury secondary to below standard of care received in regards to removal of the Hickman catheter after chem otherap y. Please be advised that I do not devote more than 20 percent of my annu al time to activities that directly involve personal injury claims. On December 2, 2005, Dr. Konits renewed his motion to dismiss on the grounds that the updated c ertificate still failed to meet the sp ecific requirements of § 3-2A-04(b). On or about the same date, Carroll waived arbitration and the matter was transferred to the Circu it Cou rt for Baltimo re City. On December 30, 2005 , Dr. Kon its filed a mo tion to dismis s in the Circuit Court for Baltimore City on the same grounds as the previous two that the certificate and report did not comply with the relevant provisions of the Statute. O n March 22 , 2006, the Circuit Court dismissed the case against Dr. Konits.6 This appeal ensued. II. Standard of Review When an appellate court reviews a trial court s grant of a motion to dismiss a complain t: [T]he truth of all well-pleaded relevant and material facts is assumed, as well as all inferences which can be reasonably drawn from the pleadings. Odyniec v. Schneider, 322 Md. 520, 525, 588 A.2d 786, 788 (1991). Generally, dism issal at the trial cou rt level will 6 The trial judge did not specify that dismissal was without prejudice. The effect of failing to sp ecif y that dismissal was with or without prejudice is that the dismissal was without prejud ice. See Maryland Rule 2-506(c) stating, in pertinent part, [u]nless otherwise specified in the notice of dismissal, stipulation, or order of court, a dismissal is without prejudice . . . . Dr. Imok e filed a sep arate motion to dismiss w hich was granted w ith prejudice. The issue of the appropriateness of the granting of that motion with prejudice, is not presented in this case. -6- only be ordered if, after assuming the allegations and permissible inferences flowing therefrom are true, the plain tiff wo uld not be aff orded r elief. McNa ck v. State, 398 Md. 378, 920 A.2d 1097, 1102 (2007) (citing Lloyd v. General Motors Corp., 397 Md. 108, 121, 916 A.2d 257, 264 (2007)). III. Discussion The Health C are Malp ractice Claim s Statute has consiste ntly been interp reted by this Court as an attem pt by the Gen eral Assem bly, in substantial p art, to limit the filing of frivolous malpra ctice cla ims. See Witte v. Azarian, 369 M d. 518, 526, 801 A.2d 160, 165 (2002) (recognizing that the General Assembly passed the Statute as part of a multi-phase response to the malpra ctice ins urance crisis th at arose in 1974 . . . . ); McCready Memorial Hosp. v. Hauser, 330 Md. 497, 500, 624 A.2d 12 49, 1251 (1993) ( [ T]he G eneral As sembly enacted the [Statute] in response to explosive growth in medical malpractice claims and the resulting effect on health care providers a bility to obtain ma lpractice insu rance. ); Attorney General v. Johnson, 282 Md. 274, 278-79, 385 A.2d 57, 60 (1978) (recognizing that: [T]he general thru st of the A ct is that medical malpractice claims be submitted to arbitration as a precondition to court action . . . . ) overruled on other grounds by Newell v. Richards, 323 Md. 717, 734, 594 A .2d 1152, 1161 (1 991). 7 What little legislative history remains from the 7 The Newell Court expressly disapproved of language in Johnson that implied that the appeals process used in under Workers Compensation Act was to be applied to claims brought under the H ealth Care M alpractice C laims Statute . The discu ssion therein on this issue has no relevance to the ca se at bar . See New ell, 323 Md. at 728-735, 594 A.2d 11581161. -7- passage of the original Statute supports this interpretation. On July 23, 1975, the President of the Senate and the Speaker of the House created the Medical Malpractice Insurance Study Committee (the Committee ) to craft and propose solutions to the medical malpractice problems confronting the State. State of Md. Medical Malpractice Ins. Study Co mm., Rep ort to the President of the Senate and the Speaker of the House, p. 1, (January 6, 1976). The Committee consisted of six Senators, six Delegates, medical experts, legal experts, hospital and insurance experts, and a representative from the Governor s office. It was charged with the task of seeking a permanent solution to the myriad problems of medical malpractice insurance facing the physicians and patients of the State of Maryland. Id. The Committee s report to the General Assembly was to be introduced for consid eration by the G eneral As sembly in its 1976 Session. Id. at 3. After reviewing position papers and conductin g public he arings on th e matter, the m ajority of the Committee reached a consensus that it was interested in some form of legislation mandating arbitratio n. Id. at 2. This consensus w as due, in part, to the fact that almost all of the testimony heard by the Committee included recommendations for some type of mechanism to screen malpractice claim s prior to the filing of the suit. 8 Id. at 3 (emphasis adde d). 8 The Maryland State Bar Association, for example, recommended to the General Assembly (it is unclear whe ther they did so directly or through the Com mittee): [T]he creation of a procedure which . . . would add an additional measure of cost predictability by encouraging resolution of disputes prior to full-scale trial in the courts. This procedure would involve non-binding pre-trial screening of all medical malpractice claims. Our proposal is as follows: (1) No person would have a cause of action f or medica l malpractice in (contin ued...) -8- Esse ntial ly, two types of screening mechanisms were suggested: (1) a medical review panel and (2) an arbitration panel. Id. at 3. The en d result of the se recomm endations was th e adoption of the Health Care Malpractice Claims Statute in 1976, for the purpose of providing for a mandatory arbitration system for all medical malpractice claims in excess of a certain amount[.] 1976 Laws of Maryland, Chapter 235. It is clear from a plain reading of the original Statute and the existing legislative history that the General Assembly intended the original Health Care Malpractice Claims Statute to screen and to first substitute the arbitration process as to malpractice claims prior to the filing of lawsuits. The Relevant Version of the Hea lth Care M alpractice C laims Statu te The Health Care Malpractice Claims Statute, establishes exclusive procedures for filing a civil action, in excess of a certain amount, against a health care provider. Maryland Code (1974, 2002 Repl. Vol., 2006 Cum. Supp.), § 3-2A-02(a) of the Courts and Judicial Proceedings Article. This was true in 1976 and is still true today. Since 1976, how ever, other aspects of the Statute have been amended. Relevantly, the 1986 amendment required the filing of a C ertificate and an attesting ex pert s report. 9 See 1986 Laws of Maryland, 8 (...continued) Maryland prior to the submission of his claim to and the issuance of a determ ination b y a pre-trial screen ing pan el. . . . Maryland State Bar Association, Report to the Special Committee to Consider Problems Related to Medical Malpractice in Maryland, p. 3. 9 In Walzer v. Osborne, 395 Md. 563 , 582, 911 A.2d 4 27, 438 (2006), we explained the difference between a Certificate and an attesting expert s report, saying: While it is arguably unclear from the Statute exactly what the expert report (contin ued...) -9- Chapter 640. By enacting the 1986 amendment, the General Assembly determined that, in the context of a medical m alpractice claim , in order to m aintain an action against a h ealth care provider, a plaintiff is required to file a Certificate and an attestin g expert s re port in addition to filing a complaint. A plaintiff mus t file a certificate of qualified expert that attests to the departure from the standard of care.10 § 3-2A-04(b)(1)(i)(1). The statute also requires that the certificate be filed with a repo rt of the attesting expert attached. § 3-2A04(b)(3)(i). The pen alty for failing to f ile the required certificate and report within 90 days (subject to a 90 day extension and the possibility of an additional good cause extension) of the filing of the complaint is dismissal without prejudice: Except as provided in subparagraph (ii) of this paragraph, a claim or action filed after July 1, 198 6, shall be dism issed, witho ut prejudice , if the claimant or plaintiff fails to file a certificate of a qualified expert with the Director 9 (...continued) should contain, common sense dictates that the Legislature would n ot require two docume nts that assert the same info rmation. Fu rthermore, it is clear from the language of the Statu te that the certificate required of the plaintiff is merely an assertion that the physician failed to meet the standard of care and that such failure was the proximate cause of th e patient-plaintiff s complaints. . . . It therefore follows that the attesting expert repo rt must exp lain how or why the physician failed . . . to meet the sta ndard of care and in clude som e details supporting the certificate of qualified ex pert. . . . [T]he ex pert report sh ould contain at least some additional information and should supplement the Certificate. Requiring an attesting expert to provide details, explaining how or why the def endant do ctor allegedly departed f rom the stan dards of c are, will help weed out non-meritorious claims and assist the plaintiff or d efendan t in evalua ting the m erit of th e health claim . . . . 10 If the defendant does not dispute liability, no certificate is required. § 3-2A04(b)(2)(ii). In the prese nt case, the ap pellees dispute liability. Thus, the certificate was required. -10- attesting to departure from standards of care, and that the departure from standards of care is the proximate cause of the alleged injury, within 90 days from th e date o f the co mplain t . . . . § 3-2A -04( b)(1 )(i)(1 ). Althou gh th e statutory scheme is slightly more complex, it is clear that unless the Certificate and the a ttached attesting expert s report are filed within a maximum of 180 days (absent the grant of a good cause exte nsio n), dismissal i s mandatory. Thus, just as a plaintif f in a med ical malprac tice claim must file a sa tisfactory com plaint, he or she mu st also file a satisf actory Certifica te and repo rt or risk dismis sal. 11 An underlying issue herein is whether the requirem ent to file a pro per Certifica te operates as a condition precedent to the maintenance of a malpractice claim. Many of our cases have recognized that the arbitration process, as a whole, was designed to be a condition precedent to the filing of a claim in a circuit court. Witte, 369 Md. at 527, 801 A.2d at 166 (reco gnizing tha t a claimant m ust file with th e HCA DRO and com ply with all statutory provisions b efore proc eeding to a circuit court); McCready, 330 Md. at 512, 624 A.2d at 1257 (finding that: T he Maryland H ealth Care Malpractice Claims Statute mandates that claimants arb itrate their claims before the [HCA DRO ] as a cond ition preced ent to maintaining suit in circuit cou rt. ); Crawford v. Leahy, 326 Md. 160, 165, 604 A.2d 73, 75 11 The determination of whether a Certificate and report are satisfactory, like the determination of whether a complaint sufficiently states a legally cognizable claim, is a determination to be made as a matter of law. As such, the standard for determining whether a Certificate or report is legally sufficient is the same as d etermining whether a compla int is legally sufficient, i.e., dismissal is only appropriate if, after assuming the truth of the assertions in the Certificate and report, and all permissible inferences emanating therefrom, the requirements set forth in the Health Care Malpractice Claims Statute are not satisfied. -11- (1992) (stating that: The manda tory arbitration requirement does not divest courts of subject matter jurisdicti on ove r health c laims, b ut rather creates a condition precedent to the institution of a co urt actio n. Upon f ulfillment of the conditio n precede nt, malpractice claims may be heard in court. (citatio ns omitted) ( quotations o mitted)); Su v. Weaver, 313 Md. 370, 377, 545 A.2d 692, 695 (1988) (recognizing that: The [Statute] substantially altered the procedure in which a medical m alpractice claim is brought a gainst a health care provider by requiring a malpractice claim to be submitted to a mandatory arbitration proceeding as a condition precedent to maintaining such an action in the circuit cou rt. ); Ott v. KaiserGeorgetown Community Health Plan, Inc., 309 Md. 641 , 645, 526 A.2d 4 6, 48-49 (1987) (stating that: If a claimant wishes to reject an award and proceed with the cause of action, the special procedures p rescribed by the Act must b e followed. ). Although it is clear that the arbitration process is a condition precedent to the filing of a claim in the Circuit Court, the qu estion still remains whether § 3-2A-04 establishes that the filing of a p roper Ce rtificate is a condition precedent to maintaining a claim for malpractice. In McCready, we stated th at the Statute re quires arbitratio n prior to pursuing a claim in the circuit court and then said: A claimant s filing of an expert s certificate is an indispensa ble step in the . . . arb itration p rocess. 330 M d. at 512, 624 A.2d at 1257 (emphas is added ). In other words, the arbitration process cannot occur without the filing of a Certificate. Thus, we conclude that the filing of a proper Certificate operates as a condition precedent to filing a claim in Circuit C ourt becau se arbitration is a condition p recedent to -12- filing a claim in a C ircuit Court a nd becau se the filing of a Certificate is an indispensa ble step in the arbitratio n proce ss, i.e., it must occur or the condition precedent is not satisfied. Therefore, if a proper Certificate has not been filed, the con dition prece dent to maintain the action has not been met and dismissal is required by the Statute once the allotted time period has elapsed . See Walzer, 395 M d. at 578, 91 1 A.2d a t 435 (con cluding tha t the Statute mandates dismissal when the claimant fails to file the Certificate within the time period allotted by the Statute); Witte, 369 Md. at 533, 801 A.2d at 169 (stating that: In the absence of a certificate signed by a qualified expert on behalf of the claimant, the case cannot proceed beyond the point at w hich the cer tificate is require d . . . . ); Goicochea v. Langworthy, 345 Md. 719, 729, 694 A.2d 474, 480 (1997) (recognizing that: Lang worthy s ma lpractice claim . . . was dismissed by the [HCADRO] because he did not file the certificate of a qualified medical expert a ttesting to the me rit of his c laim, as requ ired by § 3-2A -04(b) . . . . (Emphasis add ed)). 12 12 In Georgia -Pacific Co rp. v. Benja min, 394 Md. 59, 904 A.2d 511 (2006), we discussed the mandatory nature of conditions precedent, albeit in a different context. There we said: [A] condition precedent cannot be waived under the common law and a failure to satisfy it can be r aised at any time because th e action itself is f atally flawed if the condition is not satisfied. This requirement of strict or substantial compliance with a condition precedent is of course subject to abrogation by the General Assem bly. Georgia -Pacific Corp., 394 Md. at 84, 904 A.2d at 526 (quoting Rios v. Montg omery C ounty, 386 Md. 10 4, 127-28 , 872 A.2d 1, 14 (200 5). A statute o f limitations, on the other ha nd, is designed to: (1) provide adequate time for diligent plaintiffs to file suit, (2) grant repose to defendants when plaintiffs have tarried for an unreasonable period of time, (contin ued...) -13- Preservation for Appellate Review As a threshold issue, Dr. Imoke contends that Carroll failed to preserve her argumen ts for appellate review and that this Court should not address the merits of her arguments. He explains that Carroll conceded that she had not complied with the statutory requirements and told the trial court that her expert was in the p rocess of providing a certified statement. Dr. Imoke contends that Carroll did not submit a properly amended certified statement before the Circuit Court dism issed the cas e, and is now arguing, for the first time on appeal, that the amended letter complied with the statutory requirem ents. As such, according to Dr. Imoke, she fail ed to pr eserve these ar gume nts for a ppellate review . We note that Carroll argued, before the Circuit Court, that her initial Certificate complied with the statu tory requireme nts and told th e trial court that her expert was in the process of pro viding an am ended Certific ate. Despite the fact that Ca rroll s argum ents at the trial level pertained to the initial Certificate, we conclude that the substance of her argu ments was sufficient to preserve for appellate review the issue of whether her Certificate complied 12 (...continued) and (3) serve society by promoting jud icial economy. Georgia-Pacific Corp., 394 Md. at 85, 904 A.2d at 526 (quoting Pierce v. Johns-M anville Sales Corp., 296 Md. 656 , 665, 464 A.2d 1 020, 1026 (198 3)). We then summarized the difference between the two, saying: Further, in contrast [to a cond ition pre ceden t to main taining a n action ], a statute of limitations affe cts only the remed y, not the c ause of action. Wadde ll[ v. Kirkpatrick], 331 Md. [52,] 59, 626 A.2d [353,] 353 [(1993)]. The defense of limitations m ay be waive d; howe ver, a cond ition preced ent to liability ma y not be w aived. Rios, 386 M d. at 127 -28, 87 2 A.2d at 14. Georgia-Pacific Corp., 394 Md. at 85, 904 A.2d at 526. -14- with the requirements set forth in the Health Care Malpractice Claims Statute. The Director s Authority to Grant an Extension13 Dr. Konits argues that the Director did not have the discretion to grant Carroll an extension of time be cause it wa s not filed w ithin the 180-day period and good cause was not established. He argues, therefore, that this Court shou ld not address the propriety of D r. Simmo ns-Clem mons s p urported C ertificates of M erit. Section 3-2A-04(b)(5) states that [a]n extension of the time allowed for filing a certificate of a qualified expert under this subsection shall be granted for good c ause sh own. Similarly, § 3-2A-05(j), states: Except for time limitations pertaining to the filing of a claim or response, the Director or the panel chairman, for good cause shown, may lengthen or shorten the time limitations prescribed in subsections (b) and (g) of this section and § 3-2A -04 of this article . Dr. Konits contends that no extension could be granted fo r good ca use becau se Carroll did not request the good cause extension within the 180-day period. We rejected that exact 13 We point out that § 3-2A-02(d), provides that the Maryland Rules control the practice and proc edure arising from the H ealth Care Malpractice Claims subtitle. Section 32A-02(d ), states that: Except as otherwise provided, the Maryland Rules shall apply to all practice and pro cedure issues a rising un der this s ubtitle. Maryland R ule 1-204 (a) provide s in relevant p art: When these rules or an order of court require or allow an act to be done at or within a specified time, the cou rt, on motion of any party and for cause shown, may (1) shorten the period remaining, (2) extend the period if the motion is filed before the expiration of the period originally prescribed or extended by a previous order, or (3) on motion filed after the expiration of the specified time period, permit the act to be done if the failure to act was the result of excusable neglect. . . . (Em phasis a dded.) -15- argument in Navarro-Monzo v. Washington Adventist Hosp., 380 Md. 195, 844 A.2d 406 (2004). There we said: Appellees present the same argument to us that they raised in the Circuit Court, namely, that § 3-2A-04(b)(1)(ii) permits but one 90-day extension and that, if an y further exten sion is to be sought under either § 3-2A04(b)(5) or § 3-2A -05(j), the extension must be sought before the expiration of the 90-day extension granted under § 3-2A-04(b)(1)(ii). Relying on McCready, they aver that, once [the initial 90-day] extension period expires, the claim mu st be dismisse d. Their reliance, and the Circuit Court s reliance, on McCready is misplaced. ... We expressly recognized . . . in McCready, [] that there could conceiva bly be instances where there might be good cause to grant a request for an extension that was made after the initial ninety-day period in lieu of dismissing the claim. McCready, 330 Md. at 506 n. 5, 624 A.2d at 1254 n. 5. Indeed, §§ 3-2A-04(b)(5) and 3-2A-05(j) would have little or no meaning unless read to permit good cause extensions over and above the man datory extens ion calle d for in § 3-2A -04(b)( 1)(ii). Navarro-Monzo, 380 Md. at 200-04, 844 A.2d at 409-11. In light of our resolution of this case, we will not resolve Dr. Konits s contention that the Director lacked good cause to grant Carroll s extension. We did state in NavarroMon zo, 380 M d. at 205, 84 4 A.2d a t 412, that: Although the arbitration process itself is not in the nature of an administrative remedy, [the HCADRO] is an administrative agency within the Executive Branch of the State G overnm ent (see CJP § 3- 2A-03), a nd therefo re its Director, in administering that office, acts as an administrative official. In reviewing the administrative decisions of the Director, we must afford at least the same deference that we afford to other administrative agencies in making discretionary decisions, including, in the absence of some clear indication in the record to the contrary, an assumption that the Director is aware of the law contro lling his/h er cond uct and acts in co nform ance w ith it. Add ition ally, we explained in McCready, that the good cause exten sions are malleable[,] -16- again, generally, leaving room for the Director s discretion. 330 Md. at 509, 624 A.2d at 1255. While Carroll never mentioned the phrase good cause, in her request for an extension, she explain ed that she h ad filed he r Certificate in a timely mann er, and that its contents complied with the statutory provisions set forth in the Health Care Malpractice Claims Statute. She explained fu rther that her attesting expert was already in the process of amending the Certification to provide a dditional info rmation tha t was alread y available to her. 14 Lastly, Carroll as ked the D irector to gran t an extension based on the interests of justice. In response, the Director utilized his discretionary powers to grant the extension upon review and consideratio n of Claim ant s Ans wer To Motion To Dism iss and in the interest of justice[.] In accorda nce with the statutory language and consistent with our prior case law, we believe that the General Assembly made it clear that the good cause extensions are discretionary and without time limitations, so long as the Claimant demonstrates good cause. As indicated earlier, we need not and do not resolve the nature of the good cause asserted in this case.15 14 Carroll filed the amended Certificate only one day after the Director granted the extension. 15 We note a recent change in the law pertaining to the procedure for claims dismissed under § 3-2A -04(B )(3) of th e Statute . The General Assembly enacted Chapter 324 of the 2007 Laws of Maryland to be inserted as § 5-118 in the Courts and Judicial Proceedings Article. Its purpose clause provides: FOR the purpose of authorizing the commencement of a new civil action or claim if a prior action or claim for the same cause against the same (contin ued...) -17- 15 (...continued) party or parties was commenced within the applicable period of limitations, and was dismissed or terminated in a manner other than by a final judgment on the merits without prejudice for failure to file a certain report under certain circumstances . . . . 2007 Laws of Maryland, Chapter 324. The actual text to be inse rted as § 5-1 18 of the C ourts and Judic ial Proceed ings Article s tates that: (A) (1) THIS SECTION DOES NOT APPLY TO A VOLUNTARY DISMISSAL OF A CIVIL ACTION OR CL AIM BY THE PARTY WHO COMMENCED THE ACTION OR CL AIM. (2) THIS SEC TION AP PLIES O NLY TO A CIVIL ACTION OR CLAIM THAT IS D ISMISSED ONCE FOR F AILURE TO FILE A REPO RT IN ACCORDANCE WITH § 3-2A-04(B)(3) OF THIS ARTICLE. (B) IF A CIVIL ACTION OR CL AIM IS COMMENCED BY A PARTY WITHIN THE APPLICABLE PERIOD OF LIM ITATIO NS AN D IS DISMISSED OR TERMINATED IN A MANNER OTHER THAN BY A FINAL JUDGMENT ON THE MERITS WITHOUT PREJUDICE, THE PARTY MAY COMMENCE A NEW CIVIL ACTION OR CLAIM FOR THE SAME CAUSE WITHIN AGAINST THE SAME PARTY OR PARTIES ON OR BEFORE THE LATER OF: (1) THE EXPIRATION OF THE APPLICABLE PERIOD OF LIMIT ATIO NS; OR (2) 1 YEAR 6 MONTHS 60 DAYS FROM THE DATE OF THE DISM ISSAL ; OR (3) AUGUST 1, 2007, IF THE ACTION OR CLAIM WAS DISMISSED ON OR AFTER NOVE MBER 17, 2006, BUT BEFO RE JUNE 1, 2007 OR TERMINATION. 2007 Laws of Maryland, Chapter 324. Chapter 324 also provides how this enactment is to be construed in relation to the date it became effective: SECTION 2. AND BE IT FU RTHER EN ACTED, That this Act sha ll be construed to apply only pros pectively and may not be applied or interpreted to have any effect on or application to any action or claim dismissed or terminated before the effective d ate of this Ac t for which a final judgment has been rendered and for w hich appe als, if any, have been exhausted before the effective date of this Act. SECTION 3. AND BE IT FURTHER ENACTED, That this A ct shall take effec t October June 1, 2007 . (contin ued...) -18- The Certificate and the Report We now turn to the parties arguments regarding the Certificate and the attesting expert s report. Carroll does not challenge the existence of the condition precedent requirement discussed, supra. Instead, she presents arguments of definition, i.e., that nothing in the statutory scheme defines the words certificate or attesting, that the statute does not require a specific format, and that the words certify and attest do no t actually have to appear in the ce rtificatio n or rep ort. She also contends that the plain m eaning of the w ord attest, is to affirm to be true or g enuine , 16 and that Dr. Simmons-Clemmons submitted a docume nt in which she attested to her prof essional op inions in acc ordance w ith this definition. In addition, Carroll asse rts that the plain m eaning of the word certify only requires an affirmation in writing.17 Therefore, according to Carroll, the court erred when it dismissed the case based on a lack of formal attestation or certification. Furthermore, according to Carroll, there is no stated requirement in § 3-2A-04 that the initial certification and report actually set forth that the expert is a qualified expert or that 15 (...continued) 2007 Laws o f Maryland , Chapter 3 24. The iss ues now being pres ented in the case sub judice are not a ffecte d by this n ew stat ute. 16 Carroll cites Cloverfields Improvment Association, Inc. v. Seabreeze Properties, Inc., 32 Md. App. 421, 431-3 2, 362 A .2d 675, 68 2 (1976), in which the intermediate appellate court relied on Black s Law Dictionary 166 (3d ed. 1933) for the definition of the word attest. 17 Carroll cites Ballentine s Law Dictionary (1969) for the de finition of the word certify. -19- those qualifications have to be explained in the certificate. She also argues that there is no requirement in § 3-2A-04 that the expert u se the wo rds proxim ate cause, o r reasona ble degree of certainty. She contends that ev en though D r. Simmo ns-Clem mons did not use either of those terms, the certification makes clear that the lack of communication by appellees to Carroll conc erning the rem oval of the cath eter wa s the cau se of h er injurie s. Lastly, Carroll contends that all of Drs. Konits and Imoke s assertions fail because they are not supported by the plain language of the statute. Appellees argue that Dr. Simmons-Clemmons s documentation was deficient under the pertinent provisions the Health Care Malpractice Claims Statute for a multitude of reasons, any one of which justified the Circuit Court s dismissal of Carroll s claim. They contend that neither of the submissions from Dr. Simmons-Clemmons certified that she had clinical experience in the field practiced by Drs. Konits and Imoke within five years from the date of the alleged negligence, as is required by § 3-2A-02 (c)(2)(ii)(A), and that both letters failed to certify that Dr. Simmons-Clemmons is Board Certified in the same or related specialty as Drs. Konits and Imoke, as required by § 3-2 A-02(c)(2)(ii)(B). 18 Drs. Konits and 18 Section 3-2 A-02(c)(2 )(ii)(A) and (B ) provide in relevant pa rt: (ii) 1. In addition to any other qualifications, a health care provider who attests in a certificate of a qualified expert or testifies in relation to a proceeding before a panel or court conc erning a defenda nt s complian ce with or departure from standards of care: A. Shall have had clinical experience, provided consultation relating to clinical practice, or taught medicine in the defendant s specialty or a related field of health care, or in the field of health care in which the defendant provided care or treatment to the plaintiff, within 5 years of the date of the (contin ued...) -20- Imoke also argue that Dr. Simmons-Clemmons failed to provide any reference to her training, educatio n, profes sion al ex perience , prac tice a rea, f ield o f spe cialty, and Board Certifications; her letters merely contained the initials M.D. after her signatu re. Dr. Ko nits avers that [t]he facial defic iencies of [ Dr. Simm ons-Clem mons s] lette r/certificate are o nly exacerbated by the failure of [Carroll] to file an expert report from the certifying doctor as mand ated by [§ ] 3-2A -04(b)( 3) . . . . 19 Dr. Konits also argues that neither of Carroll s letters identified the health care professional(s) against whom her claims applied. Dr. Konits notes that the letters reference five physicians -- Dr. Konits, Dr. Imoke, Dr. Ohio, an unidentified cardiologist, and an unidentified primary care physician. Furthermore, according to Dr. Konits, both letters failed to articulate opinions to a reasonab le degree of med ical probability, as is required by Maryland law. Dr. Konits contends that Dr. Simmons-Clemmons s letter is not an appropriate Certification or Attestation of expert opinions but, instead, was an informal letter addressed to Carroll s attorney from Dr. Simmons-Clemmons. Dr. Konits further contends that Carroll s initial letter from Dr. Simmons-Clemmons was deficient because the 18 (...continued) alleged act or omission giving rise to the cause of action; and B. Except as provided in item 2 of this subparagraph, if the defendant is board certif ied in a spec ialty, shall be board certified in the same or a related specialt y as the de fenda nt. 19 Section 3-2 A-04(b) (3)(i) provide s, as relevant: The attor ney re pres entin g eac h party, or the party proceeding pro se, shall file the app ropriate certifica te with a report o f the atte sting ex pert attac hed. -21- physician failed to state th e amoun t of profes sional time spen t in testimonial activities for personal injury claims and Dr. Imoke also asserts that the initial letter was deficient because Dr. Simmons-Clemmons failed to attest to the departures from the standards of care. Statutory Construction This case requires us to construe several provisions of the Health Care Malpractice Claims Statute and is primarily a matter of statutory interpretation. The first provision relevant to the case sub judice is § 3-2A-04(b) of the Courts and Judicial Proceedings Article. This section states, in pertinen t part: (b) Filing and service of certificate of qualified expert. -- Unless the sole issue in the cla im is lack of informed consent: (1) (i) 1. Excep t as prov ided in s ubpara graph ( ii) of this p aragrap h, a claim or action filed after July 1, 1986, sh all be dismissed, without prejudice, if the claimant or plaintiff fails to f ile a certificate o f a qualified expert w ith the Directo r attesting to depa rture fro m stand ards of care, and that the departure from standards of care is the proximate cause of th e alle ged injury, within 90 days from th e date of th e compla int; ... (2) (i) A claim o r action filed a fter July 1, 1986 , may be adjud icated in favor of the claimant or plaintiff on the issue of liability, if the defendant disputes liability and fails to file a certificate of a qualified expert attesting to compliance with standards of care, or that the departure from standards of care is not the proximate cause of the alleged injury, within 12 0 days from the date the claimant or plaintiff served the certificate of a qualif ied expert se t forth in paragraph (1) of this sub section on th e defend ant. ... (3) (i) The attorney representing each party, or the party proceeding pro se, shall file the appropriate certificate with a rep ort of the attesting expert attached. ... (4) A health care provider who attests in a certificate of a qualified -22- expert or w ho testifies in relation to a proceeding before an arbitration panel or a court concerning compliance with or departure from standards of care may not devote annually more than 20 percent of the expert s professional activities to activities that directly involve testimony in personal injury claims. (5) An extension of the time allowed for filing a certificate of a qualified expert under this subsection shall be granted for go od cau se show n. Maryland Code (1974, 2002 R epl. Vo l., 2006 C um. Su pp.), § 3-2A-02 of the Co urts and Judic ial Proceed ings Article is also relevan t and states, in p ertinent part: (2) (i) This paragraph ap plies to a claim or action filed on o r after January 1, 2005. (ii) 1. In addition to any other qualifications, a health care provider who attests in a certificate of a qualified expert or testifies in relation to a proceeding before a panel or court concerning a defenda nt s comp liance with or departure from standards of care: A. Shall have had clinical experience, provided consultation relating to clinical prac tice, or taught m edicine in the defendant s specialty or a related field of health care, or in the field of health care in which the defendant provided care or treatment to th e plaintiff, w ithin 5 years of th e date of the alleged act or omission giving rise to the cause of action; and B. Except as provided in item 2 of this subparagraph, if the defendant is board certified in a specialty, shall be board certified in the same or a related sp ecialty as the def endant. 2. Item (ii)1.B of this subparagraph does not apply if: A. The defendant was providing care or treatment to the plaintiff unrelated to the area in which the defendant is board certified; or B. The health care provider taught medicine in the de fendant s specialt y or a relate d field o f health care. The rules of statutory construction are well settled in this State. This Co urt recently outlined those rules in Walzer v. Osborne, 395 Md. 563, 571-74, 911 A.2d 427, 431-33 (2006), where we stated: The cardinal rule of statutory construction is to ascertain and effectuate the intent of the Legislature. Mayor and Town Council of Oakland v. Mayor and Town Council of Mountain Lake Park, 392 Md. 301, 316, 896 A.2d 1036, -23- 1045 (2006); Chow v. State, 393 Md. 431, 443, 903 A.2d 388, 395 (2006) (citation s omitte d) . . . . As this Court has e xpla ined , [t]o dete rmin e tha t purpose or po licy, we look first to the language of the statute, giving it its natural and ordinary mean ing. State Dept. of Assessments and Taxation v. Maryland-Nat l Capital Park & Planning Co mm n, 348 Md. 2, 13, 702 A.2d 6 90, 696 (1997); Montgomery County v. Buckman, 333 Md. 516, 523, 636 A.2d 448, 452 (1994 )[.] We do so on the tacit theory that the L egislature is pre sumed to have meant w hat it said and said wha t it meant. Witte v. Azarian, 369 Md. 518, 525, 801 A.2d 160, 165 (2002 ). When the statutory language is clear, we need not look b eyond the statu tory language to determ ine the Legislature s intent. Marriott Employees Fed. Credit Union v. MVA, 346 Md. 437, 445, 697 A.2d 455, 458 (1997). If the words o f the statute, co nstrued acc ording to the ir common and everyday meaning, are clear and unambiguous and express a plain meaning , we will giv e effect to th e statute as it is written . Jones v. Sta te, 336 Md. 255, 261, 647 A.2d 1204, 1206-07 (1994). In addition, [w]e neither add nor delete w ords to a clea r and una mbiguo us statute to give it a meaning not reflected by the words the L egislature used or engage in forced o r subtle interpretation in an attemp t to extend or limit th e statute s mean ing. Taylor v. NationsBank, N.A., 365 Md. 166, 181, 776 A.2d 645, 654 (2001). If there is no ambiguity in th[e] languag e, either inhe rent ly or by reference to other relevant laws or circumstances, the inquiry as to legislative intent ends . . . . Chow, 393 Md. at 443-44, 903 A.2d at 395. If the language of the s tatute is ambiguous, how ever, then courts consider not only the literal or usual meaning of the words, but their meaning and effect in light of the setting, the objectives and purpose of [the] enactment [under consid eration] . Fraternal Order of Police v. Mehrling, 343 Md. 155, 174, 680 A.2d 1052, 1062 (1996) (quoting Tucker v. Fireman s Fund Ins. Co., 308 Md. 69, 75, 517 A.2d 730, 732 (1986)). We have said that there is an ambiguity within [a] s tatute wh en there ex ist two or m ore reason able alternative interpretations of the statute. Chow, 393 Md. at 444, 903 A.2d at 395 (citations omitted). When a statute c an be interpreted in mo re than one way, the job of this Court is to resolve that ambiguity in light of the legislative intent, using all the resources and tools of statutory construction at our disposal. Id. If the true legislative intent cannot readily be determined from the statutory lang uage alo ne, h owe ver, w e ma y, and often must, resort to other recognized indicia among other things, the structure of the statute, including its title; how the statute relates to other laws; the legislative history, including the derivation of -24- the statute, comments and explanations regarding it by authoritative source s during the legis lative pr ocess, and amendm ents proposed or added to it; the general purpose behind the statute; and the relative rationality and legal effect of various comp eting co nstructio ns. Witte, 369 Md. at 52 5-26, 801 A.2d at 165. In construing a statute, [w]e avoid a constructio n of the statu te that is unrea sonable, illogical, or inconsistent with commo n sense. Blake v. Sta te, 395 M d. 213, [224,] 909 A.2d 1020, [1026] (2006) (citing Gwin v. MVA, 385 Md. 440, 462, 869 A.2d 822, 835 (2005 )). In addition, the meaning of the plainest language is controlled by the context in which it appears. State v. Pagano, 341 Md. 129, 133, 669 A.2d 1339, 1 341 (1 996) (c itations o mitted). A s this Co urt has s tated, [b]ecause it is part of the context, related statutes or a statutory scheme that fairly bears on the fundamental issue of legislative purpose or goal must also be considered. Thus, not only are we required to interpret the statute as a whole, but, if appropriate, in the context of the entire statutory scheme of which it is a part. Gordon Family P ship v. Gar On Jer, 348 Md. 129, 138, 702 A.2d 753, 757 (1997) (citations omitted). Lastly, [s]tatutes in derogation of the common law are strictly construe d, and it is not to be presumed that the legislature by creating statutory assaults intended to make any alteration in the common law other than w hat has been sp ecified and pla inly prono unced . . . . Most statutes, of course, change the common law, so that principle [of narrow construction] necessarily bends when there is a clear legislative intent to make a change. Witte, 369 M d. at 533 , 801 A .2d at 16 9. Walzer, 395 Md. at 571 -74, 911 A.2d at 43 1-33 (some citations om itted). As stated, supra, § 3-2A-04(b)(1)(i)(1) of the Courts and Judicial Proceedings Article, requires that: [A] claim o r action f iled afte r July 1, 19 86, sha ll be dism issed, w ithout prejudice, if the claimant or plaintiff fails to file a certificate of a qualified expert with the Director attesting to departure from standards of care, and that the departure from standards of care is the proximate cause of the alleged injury. (Em phasis a dded.) -25- Appellees interpret the above language as requiring the purported Certificate submitted by Dr. Simmons-Clemmons attest to a breach of the standard of care and that the breach was the proximate cause of Carroll s injuries.20 We agree. Th e ordinary meaning of the word attest is [t]o bear witness; testify or [t]o affirm to be true or genuine[.] Black s Law Dictionary 138 (8th ed. 1999). Reading § 3-2A-04(b)(1)(i)(1) in conju nction with this definition, we conclude that the language of this provision is clear and unambiguous and we need not resort to statutory interpretation. According to the plain language, a Certificate, under § 3-2A-04(b), must contain the qualified expert s affirmatio n as to two separate conditions (1) that the defendant-physician departed from the standards of care, and (2) that such a dep arture w as the pro ximate c ause of plaint iff s alleg ed in jury. In examining Dr. Simmons-Clemmons s purported replacement Certificate, we conclude that even if she had satisfied the first stated requirement, she failed to satisfy the second requirement. The pertinent language of Dr. Simmons-Clemmons s second certificate, in which she discussed her professional medical opinion in reference to Carroll s medical care, is as follows: [I]t does appear that Mrs. Mary Carroll suffered complications arising from having the catheter in place for longer than what is standard treatment[,] (i.e. a DVT and chronic venou s stasis of the right arm with chronic lymph edema.[)] 20 Appellees articulated at oral argument seven specific requirements that Carroll must have satisfied before her Certificate could be complete under the Health Care Malpractice Claims Statute and Carroll argued that she complied fully with the requirements of the Statute based on the its plain langu age. We agree that C arroll failed to comply with certain statutory provisions that are required. -26- Dr. Simmons-Clemmons explained in the Certificate that the catheter was in place for longer than what is standard treatment and that the treatment that Carroll received was below standard of ca re[.] Th e firs t con ditio n under § 3-2A -04( b), ar guably, may have been satisfied. As to the se cond and unsatisfied r equireme nt, Dr. Simm ons-Clem mons state d that: It is my professional opinion that Mrs. Carroll suffered injury second ary to below standard of care received in regards to removal of the Hickman catheter after ch emoth erapy. We assume that when Dr. Simmons-Clemmons stated that Carroll s injury was second ary to below standard of care[,] that she meant the treatment given to Carroll fell below the standard of care. N otwithstand ing this assumption, Dr. Simmons-Clemmons failed to state, with clarity, that the treatment Carroll received or failed to rece ive, fell below the standard of care and was the proximate cause of her injuries. In fact, at no point, did she state that the alleged departure from the standard of care was the proximate cause of Carroll s injuries.21 21 We recognize that proximate cause is a legal term. We do not think, however, that its meaning, in this context, is so obtuse that a person would need to spend a great deal of time studying the definition to understand its meaning. With respect to proximate cause, we have said: Variou sly stated, the universally accepted ru le as to the pro ximate cause is that, unless an act, or omission of a duty, or both, are the direct and continuing cause of an injury, recovery will not be allowed. The negligent acts must continue th rough every event and occurrence, and itself be the natural and logical cause of th e injury. It must be the natural an d probab le consequence of the negligent act, unbroken by any intervening agency, and where the negligence of any one person is merely passive, and potential, wh ile the negligence of another is the moving and effective cause of the injury, the (contin ued...) -27- Drs. Konits and Imoke also interpret the language of § 3-2A-04(b) as requiring that the Certificate id entify the specif ic individua l or individua ls who breached the standard of care. According to Drs. Konits and Imoke, the purported Certificate is incomplete because it fails to identify specifically the licensed professionals against whom Dr. SimmonsClemmons s claims applied. Again, we agree. Maryland law requires that the Certificate mention explicitly the name of the licensed professional who allegedly breached the standard of care. See Witte, 369 Md. at 521, 801 A.2d at 162 (explaining that unless . . . the claimant files with the [Health Care Alternative Dispute Resolution Office] a certificate of a qualified expert attesting that the defendant s conduct constituted a departure from the standard of care and that the departure was the proximate cause of the allege d injury, the claim must be d ismissed . . . ) (em phasis added); McCready, 330 Md. at 500, 624 A.2d at 1251 (articulating that the plaintiff must file a Certificate of Qualified Expert (expert s certificate) attesting to a defendant s departure from the relevant standards o f care wh ich proxim ately caused the plaintiff s inju ry ) (emphas is added); Watts v. King, 143 M d. App . 293, 30 6, 794 A .2d 723 , 731 (2002) (stating that 21 (...continued) latter is the proxim ate cau se and f ixes the liability. Bloom v. Good Humor Ice Cream Co., 179 Md. 384, 387, 18 A.2d 592, 593-94 (1941) (citations omitted). Alternatively, Black s Law Dictionary 234 (8th ed. 2004), provides a generally applicable definition of proximate cause: 1. A cause that is legally sufficient to result in liability; an act or omission that is considered in law to result in a consequence, so that liability can be imposed on the actor. 2. A cause that directly produces an event and without which the eve nt wou ld not h ave oc curred . -28- claimants are required to file a certificate of a qu alified expe rt attesting that the licensed professional against whom the claim was f iled breach ed the stand ard of care . ) (empha sis added); D Angelo, 157 Md. A pp. at 646, 853 A .2d at 822 (concluding that the expert s certificate must include the name of the licensed professional aga inst whom the claim s were brought because, w ithout that info rmation, the certificate req uirement w ould amo unt to a useless forma lity that wo uld in n o way h elp we ed out n on[-]m eritoriou s claims . ). We believe that this requirement is consistent with the G eneral As sembly s inten t to avoid nonmeritorious claims. Moreove r, it is reasonable because the Certificate would be rendered useless without an identification of the allegedly negligent parties. When a Certificate does not identify, with some specificity, the person whose a ctions shou ld be evalu ated, it wou ld be impossible for the opp osing party, the HCADR O, and the courts to ev aluate whether a physician, or a particular physician out of several, breached the standard of care. In the instant case, Dr. Simmons-Clemmons filed a certificate that included the names of five different physicians, two of wh om are the nam ed defendants in this cas e. The report mentioned Dr. Imoke and Dr. Konits, but also mentioned a Dr. Ohio, an unnamed cardiologist, and an unnam ed primary care physician. Dr. Simmons-Clemmons then stated very generally that there w as no cl ear com munic ation to t he patie nt . . . . In so doing, Dr. Simmons-Clemmons failed to state with su fficient spe cificity which physician or physicians breached the standard of care and which physician or physicians w ere allegedly resp onsible for Carroll s inju ries. Equally egre gious, how ever, is that the Certificates failed to state what -29- the standard of care w as or how Dr. Imok e or Dr. K onits depar ted from it. What was the sta ndard of care expe cted of the m? W hat duty did eithe r have in regard to removing the cathe ter? Was Dr. Konits, the oncologist, supposed to remove the catheter, inserted surgically by Dr. Imoke, upon the termination of chemotherapy? Was he supposed to call Dr. Imoke to inform him that the chemotherapy had been completed? Was he supposed to tell Carroll to call Dr. Imoke? Was Dr. Imoke supposed to call Dr. Konits from time to time to check on the progress of the chemotherapy? Was he suppo sed to call Carroll from time to time for that purpose? Was he supposed to tell Carroll to call him when she completed chemotherapy? The Certificate stated that the patient was to follow-u p with D r. Imoke in September, 2002[]" a year after the mastectomy but it does not indicate where that information came from or wh ether D r. Kon its was, o r should have b een, aw are of th at fact. T he Certif icate stated that there was mention made of an approximate time chemo[therapy] should be completed by Dr. Konits in his consult dated January 31, 2002, but it does not say when that time was, or how it related to the a nticipated fo llowup w ith Dr. Imok e in September, 2002. Interestingly, the complaint indicates that chemotherapy was completed in April, 2002, but the Certifica te does no t note that fac t. The Certificate adds that Carroll was not recalled for her September 2002 followup. Was Dr. Kon its responsible for that? Was D r. Imoke res ponsible fo r that? Did Carroll know she was supposed to follow up with Dr. Imoke? There is no indication that either -30- defendant acted as Carroll s primary care ph ysician. Was that unidentified doctor supposed to keep track of the chemotherapy and alert Carroll to the need to have the catheter removed? Was either defendant supposed to comm unicate w ith Carroll s p rimary care ph ysician in this regard? A general assertion, such as the one made by Dr. Simmons-Clemmons, that there was no clear communication to the patient by unspecified doctors regarding the timing of the removal of the catheter is deficient in two respects. Dr. Simmons-Clemmons did not explain in the Certificate the requisite standard of care owed to Carroll. Simmons-Clemmons also failed to state which doctor, or doctors, owed Carroll a specific duty under that standard. Without such statem ents by Dr. Simmons-Clemmons, the deficiencies in both the first and second Certificate go well beyond the issue of identity and proximate cause. The Certificates are wholly lackin g in any assertion that either defendant de parted from an ap plicable standard of care. Th ey do not eve n come c lose to com plying with the statutory requirem ent. We therefore conclude that the alleged Certificate was also deficient in this respect and that the Circuit Court was correct in dismissing the case on the gro unds that C arroll failed to file a proper Certificate. This con clusion is in accordance w ith this Court s interpretation of the application of the statutory requirements for the filing of medical malpractice claims. Our cases are consistent with this conclusion. In McCready, we stated th at: The basic procedu res for initiating and main taining a claim under the S tatute are clear and simple. The Statute requires that a person with a medical -31- malpractice claim first file that claim with the Director o f the Health [Ca re Alternative Dispute Resolution] Office[]. § 3-2A-04(a). Thereafter, the plaintiff must file a certificate of qualified expert (expert s certificate) attesting to a defendant s departure from the relevant standards of care which proxim ately caus ed the p laintiff s injury. § 3 -2A-0 4(b)(1) (i). 330 Md. at 500-01 , 624 A.2d at 1251; Odyniec, 322 Md. at 533, 588 A.2d at 792 (in the context of explaining the operation of the statute, we opined that: The Act requires a claimant at the commenc ement of the action to f ile a certificate prepared by a qualified exp ert stating that the practitioner departed from the standard of care and that such departure was the proximate cause o f the injury. . . . ); see also D Angelo , 157 Md. App. at 634, 649, 853 A.2d at 824 (outlining the steps for bringing a me dical malpractice claim). Even if we were to have found an ambiguity in the Statute, which we do not, the legislative history surrounding the enactment of the 1986 legislation supports our holding. That year, the Gen eral Assem bly was aga in confronted with a medical malpractice crisis. In response, the Assembly enacted changes to almost every section in the Health C are Malpractice Claims Statute, including the one relevant to the present case--§ 3A-02-04. As relevant to this case, the General A ssembly inserted the following language into § 3A-02-04: (1) A CLAIM FILED AFTER JULY 1, 1986, SHALL BE DISMISSED, WITHOUT PREJUDICE, IF THE CLAIMANT FAILS TO FILE A CERTIFICATE OF A QUALIF IED EXPERT WITH THE DIRECTOR ATTESTING TO DEPARTURE FROM STANDARDS OF CARE . . ., AND THAT THE DEPARTURE FROM STANDARDS OF CARE . . . IS THE PROXIMATE CAUSE OF THE ALLEGED INJURY, WITHIN 90 DAYS FROM THE DATE OF THE COMPLAINT. ... (3) THE ATTORNEY REPRESENTING EACH PARTY, OR THE PARTY PROCEEDING PRO SE, SHALL FILE THE APPROPRIATE -32- CERTIFICATE WITH A REPORT OF THE ATTESTING EXPERT ATTACHED. DISCOVERY IS AVAILABLE AS TO THE B ASIS OF THE CER TIFIC ATE . 1986 Laws of Maryland, Chapter 640. Referring to the 1985 Joint Report of the Executive/Legislative Task Force on Medical Malpractice Insurance, the Summary of Com mittee Report stated that the: Task Force voted to adopt the concept of a certificate of merit by a vote of 17 to 0, and the concept of a certificate of a meritorious defense by a vote of 11 to 8. This provision is designed to reduce the number of frivolous claims and defenses. Summary of Committee Report, S.B. 559, p. 4 (em phasis add ed). That the Certificate requirement was inten ded to curta il frivolous m alpractice claim s could only be more clearly demonstrated if the Gen eral Assem bly had place d the abov e empha sized langu age in § 3-2A04 itself. Although this statemen t alone is enough to persuad e us that the G eneral As sembly intended the new provision of § 3-2A -04 to limit frivolous law suits, the evolu tion of certain language in S.B. 559 is additional e vidence o f such inten t. The above underlined portions of subparagraph one indicate amendments to the original version of S.B. 559. According to the Summary of Committee Report, the Judicial Proceedings Committee added language to the original bill that required the certifying expert to state: THAT THE DEPARTURE FROM STANDARDS OF CARE . . . IS THE PROXIMATE CAUSE OF THE ALLEGED INJURY[.] This language, requiring a specific statement of causal connection, was clearly intended to be another way (the first being the Certificate itself) to substantiate the merit of the claim bein g filed. Because this language -33- remained in the final version of S.B. 559, the one that was enacted into law, the requirement is further evidence of the G eneral Assemb ly s desire to make sure claims being filed were not frivolous. The thrust of the two 1986 amendments is to substantiate the claim being filed. Moreover, the 1986 amen dments are consistent with the intent of the o riginal enactm ent in 1976, i.e ., to screen m alpractice c laims prior to the filing of su it. In light of our c onclusion that the plain language of § 3-2A-04 requires the filing of a proper Certificate and proper attesting expert s report, we need not address the other issues raised by the parties. IV. Conclusion For the foregoing reasons, we hold that a Certificate is a condition precedent and at a minimum, must identify with specificity, the defendant(s) (licensed professional(s)) against whom the claims are brought, include a statement that the named defendant(s) breached the applicable standard of care, and that such a departure from the standard of care was the proximate cause of the plaintiff s injuries. In the case sub judice, the certificate was incomple te because it failed to specifically identify the licensed professionals who allegedly breached the standard of care and failed to state that the alleged departure from the standard of care, by whichever doc tor, or doctors, the expert failed to identif y, was the pro ximate cause of Carroll s injuries. Therefore, because the Certificate is a condition precedent, the Circuit Court for Baltimore City correctly granted the appellees motion to dismiss the case and, accordingly, w e aff irm th e jud gme nt of the C ircuit Co urt for Baltim ore C ity. -34- Judg e Ha rrell joins in th e jud gme nt on ly. JUDGMENT OF THE CIRCUIT COURT FOR BALTIMORE C I T Y A F F I R M E D . APPELLANT TO PAY THE COSTS. -35- IN THE COURT OF APPEALS OF MARYLAND No. 117 September Term, 2006 MARY CARROLL v. PHILLIP H. KONITS, M.D., ET AL. Bell, C.J. Raker Cathell Harrell Battaglia Greene Wilner, Alan M . (retired, specially assigned), JJ. Concurring Opinion by Harrell, J. Filed: July 27, 2007 I reluctantly concur in the result reached by the Majority opinion. Although I agree generally with the Dissent s analysis of the sufficiency of Dr. Simmons-Clemmons 27 October 2005 letter re port, I do not think it is the appropriate report to analyze in this case. Both the Majority opinion and the Dissent glide smoothly past the fact that C arroll failed to present any cause, let alone good cause, to the Health Claims Alternative Dispute Resolution Office (HCADRO) for the needed extension of time to supplement her 3 Augu st 2005 rep ort. The August 3 report asserts that Dr. Simmons-Clemmons completed a review of the medical records in formula ting her repo rt. Her Answer To Motion To Dismiss before the HCADRO, in which she requested, in the interest of justice, an extension of time to file u ltimately what was to become the October 27 version, offered absolutely nothing in the way of good cause for an extension. She did not claim any factual or legal basis for not being in a position for her certifying doctor s August 3 report to have included everything required to be included there. Accordingly, the grant of the good cause extension by the HCADRO, on this record, was clearly erroneous as a matter of law and arbitrary and capricious as lacking any factual basis for good cause. Confining consideration to the August 3 version (the only report properly before the Court), I am unable to join the Dissent, which places great weight in its analysis on the substantive additions found only in the October 27 version. In the important concluding lines of the August 3 report, the doctor states: Thir dly, it does appear that Mrs. Mary Carroll suffered complications arising from having a catheter in place for too long, i.e. A DVT -37- and chronic venous stasis of the right arm with chronic lymph edema. (emphasis added ). In the conclu ding lines of the Octob er 27 repo rt, Dr. Simmons-Clemmons revised somewhat and supplemented this language: Thir dly, it does appear that Mrs. Mary Carroll suffered complications arising from having a c atheter in place for longer than what is standard treatment, i.e. a DVT and chronic venous stasis of the right arm with chronic lymph edema. It is my professional opinion that Mrs. Carroll sustained injury secondary to below standard of care received in regards to removal of the Hickman catheter after chemotherapy. Please be advised that I do not devote more than 20 percent of my annual time to activities that directly involve personal injury claims. (emphasis added ). Without the modified and added language in the October 27 rep ort, the Dissent s reasoning does not hold up: In examining Dr. Simmons-Clemmons s amended Certificate, it is clear that she satisfied the two stated requirements [departure from standard of care and proximate cause]. The pertinent language of Dr. Simmons-Clemmons s second certificate, in which she discusses her professional medical opinion in reference to Mrs. Carroll s medical care, is as follows: [I]t does appear that Mrs. Mary Carroll suffered complications arising from having the catheter in place for longer than what is standard treatment[,] (i.e. a DVT and chro nic venous stasis of the right arm with chronic lymph ede ma.[)] It is my professional opinion that Mrs. Carroll suffered injury secondary to below standard of care received in regards to removal of the Hickman catheter after chem othe rapy. Dr. Simmons explained in the Certificate that the catheter was in place for -2- longer than what is stan dard treatm ent and that the treatment that Mrs. Carroll received was below standard of care. She therefore satisfied the first condition. As to the second requirement, Dr. Simmons-Clemmons stated that there was no clear communication to the patient that indicated she should seek medical attention in the removal of the catheter from her chest after chemotherapy was completed, and further that Mrs. Carroll suffered injury secondary to below standard of care received in regards to removal of the Hickman catheter after chemotherapy. Dissent, slip op. at 1-2. Acc ordingly, I am com pelled to join the judgment reached by the Majority in this case. -3- In the Circu it Court for B altimore C ity No. 24-C-05-011066 ARG UED: 4/11/07 E-MAILED: 6/29/07 IN THE COURT OF APPEALS OF MARYLAND No. 117 September Term, 2006 _________________________________________ MARY CARROLL v. PHILLIP H. KONITS, M.D., ET AL _________________________________________ Bell Raker Cathell Harrell Battaglia Greene Wilner, Alan M . (Retired, Specially Assigned), JJ. _________________________________________ Dissenting Opinion by Greene, J. which Bell, C.J. joins _________________________________________ Filed: July 27, 2007 I agree with the majority that Mrs. Carroll preserved for appellate review her argumen ts concerning the propriety of Dr. Simmons-Clemmons s Certificate and also that the Director had the authority and discretion to grant Mrs. Carroll s extension. I also agree that a Certific ate must identif y the health care provider ag ainst who m the claim is brought, and the certifying expert must attest to facts that support the allegation that the hea lth care provider s conduct breache d the applicable standard of care and that such a departure from the standard of care proximately caused the plaintiff s injuries. In this case, howe ver, I believe that Mrs. Carroll submitted a Certificate that satisfied those minimum requirements. Therefore, the Circuit C ourt was in correct to grant the appellees motion to dismiss the case and, accordingly, I wou ld revers e the judg men t of th e Cir cuit C ourt for B altim ore C ity. As stated supra, § 3-2A-04(b)(1)(i) of the Courts & Judicial Procee dings Artic le states that a claim or action filed after July 1, 1986, shall be dismissed, without prejudice, if the claimant or plaintiff fails to file a certificate of a qualified expert with the D irector attesting to departure from standards of care, and that the departure from standards of care is the proximate cause of the alleged injury. . . . (Empha sis added.) T he majority interp rets this langu age as requ iring that the C ertificate contain the qualifie d expert s affirmation that the defendant-physician departed from the standards of care and that such a departure was the proximate cause of plaintiff s alleged injury. I agree with that interpretation. In examining Dr. Simmons-Clemmons s amended Certificate, it is clear that she satisfied the two stated requirements. The pertinent langua ge of Dr. Simm ons-Clemmo ns s second certificate, in which she discusse s her professional me dical opinion in reference to Mrs. Carroll s medical care, is as follows: [I]t does appear that Mrs. Mary Carroll suffered complications arising from having the catheter in place for longe r than what is standard treatme nt[,] (i.e. a DVT and chronic venous stasis of the right arm with chronic lymph edema.[)] It is my professional opinion that Mrs. Carroll suffered injury secondary to below standard of care received in regards to removal of the Hickm an cath eter afte r chem otherap y. Dr. Simmons-Clemmons exp lained in the Certificate that the catheter was in place for longer than wh at is standard treatment and that the treatment that Mrs. Carroll received was below standa rd of ca re. She therefo re satisfi ed the f irst cond ition. As to the second requirement, Dr. Simmons-Clemmons stated that there was no clear communication to the patient that indicated she should seek medical attention in the removal of the catheter f rom her ch est after chemotherapy was completed, and further that Mrs. Carroll suffered injury secondary to below standard of care received in regards to removal of the Hickman catheter after chemotherapy. While Dr. Simmons-Clemmons never used the term proximate cause to explain the cause of Mrs. Ca rroll s injuries, she stated specif ic facts which causally linked the health care providers breach of the standard of care to Mrs. Carroll s injuries. The substance of what Dr. Simmons-Clemmons said is obvious and is eviden ce of th e cause of M rs. Carro ll s injurie s. It is well settled th at several ne gligent acts m ay work tog ether to cause an injury, and that each person whose negligent act is a cause of an injury may be lega lly respon sible. See -2- Atlantic Mutual Insurance Co. v. Kenney, 323 Md. 116, 127, 591 A.2d 507, 512 (1991) ( Negligence which constitutes a proximate cause of an injury need not necessarily be the sole cause . . . . In order to be a proximate cause, the negligence must be 1) a cau se in fact, and 2) a legally cognizable c ause. ); see also Petersen v. Underwood, 258 Md. 9, 17, 264 A.2d 851, 855 (1970). Moreover, proximate cause is a legal term and not a medical term. Dr. Simmons-Clemmons s certification of facts, with regard to causation, was consistent with the statutory requirements of § 3-2A-04(b) that the person making the certification must be a health care provider and attest to the facts that support the allegation that a health provider s conduct breache d the standard of care a nd the departure from the standard of care prox imat ely caused the a llege d injury. 1 As stated supra, the purpose of the Certificate is to reduce the number of nonmeritorious claims bein g submitted to the Health Care Alternative Dispute Resolution Office. Dr. Simmons-Clemmons, through her attestation, demonstrated that Drs. Konits and Imoke failed to communica te with each other and that such a failure caused M rs. Carroll s catheter to remain in place for more than two years longer than what is standard medical procedure. 1 The majority recognizes that proximate cause is a legal term but states that [w]e do not think, howeve r, that its meaning, in this context, is so obtuse that a person would need to spend a great deal of time stud ying the defin ition to unde rstand its meaning . I agree w ith this statement. I disagree, howe ver, that an af firmation f rom an atte sting physician th at a defenda nt-health care provider acted in such a way that makes clear that his or her conduct was the p roximate caus e of a plain tiff s alle ged injury, fails to satisfy the statutory requireme nts simply becau se it fails to includ e the mag ic words, p roximate cause. I believe that the substance of the statement is more important than the inclusion of the specific legal termino logy or co nclusio n. -3- Dr. Simmons-Clemmons also makes clear that because the catheter was left in place for so long, Mrs. Carroll suffe red injuries. I would therefore hold that M rs. Carroll also satisfied the second stated require ment. The majority also interprets the language of § 3-2A-04(b) as requiring that the Certificate identify the specific individual or individuals who breached the standard of care. I agree. I disagree with the majority, however, that Mrs. Carroll s C ertificate is inco mplete because it fails to comply with this requirement. I acknowledge that Dr. Simmons- Clemmons filed a statement that included the names of five different physicians, only two of whom are the named health care providers/appellees in this case. The Certificate, however, specifically mentioned Dr. Imoke and Dr. Konits and made clear that the physicians failed to comm unicate to M rs. Carroll that her catheter needed to be removed after she completed chemothe rapy. Mrs. Carroll mad e clear that Dr. Imoke w as the health care provider who placed the catheter inside her chest and that Dr. Konits s failure to con tact Dr. Imoke and make him aware that the catheter could be taken out, resulted in it being left inside her chest for two and one-half years.2 I would therefore c onclude th at the Certific ate 2 Rec ently, in Barber v. Catholic Health Initiatives, Inc., 174 Md. App. 314, 921 A.2d 811 (2007), the in termediate a ppellate court examined previous health care claims cases of this State, including this Court s decision in Walzer, and determ ined that the id entity of the physicians who allegedly breached the standard of care must be discernable from the Certificate, and that a f ailure to do so will result in dism issal. In that case, the cla imant named all twelve defendants in the original claim and defined them collectively as the Health Care Pro viders. Th e court dete rmined tha t it was clear from the Certificate, about whom the physician was speaking, when th e attesting ph ysician explaine d that the H ealth Care Providers breache d the standard of care. The court stated that [t]he Certificate cannot (contin ued...) -4- satisfied the requiremen ts in this regard and the C ircuit Court w as therefore incorrect to dismiss the case on the grounds that Mrs. Carroll failed to file a proper Certificate. The purpose of the statute is to weed out non-meritorious claims, not to dismiss meritorious claims for frivolous reasons. The majority does not address the other contentions made by Drs. Konits and Imoke. I believe it is important for the Co urt to address these contentions. Drs. Konits and Imoke contend that the Cer tificate must s tate that Dr. Simmons-Clemmons spends no more than 20 percent of her pro fessional time on personal injury-related litigation, that she is board certified in the same fields as Drs. Konits and Imoke and that she has a similar medical background to Drs. Konits and Imoke. I would reject these contentions. The 20 percent declaration is not at issue in this case because D r. Simmo ns-Clem mons ex plicitly stated in her amended certificate that she spends no more than 20 percent of her time on personal injury claims. No twithstandin g, I do not rea d the Hea lth Care M alpractice C laims Statute to require that the Certificate include any of this information. Section 3-2A-04(b)(4) states that: A health care p rovider w ho attests in a c ertificate of a qualified expert or who testifies in relation to a proceeding before an arbitration panel or 2 (...continued) be analyzed in a vacuum; it must be considered in the context of the Statement of Claim that it supported, which had already been filed with the HCAO. The court noted, however, that [t]o be sure, if ap pellants had re-named in the Certificate each person or entity listed in the Statement of Claim, this appeal would have been avoided (slip op. at 42). I agree that the inclusion of the specific names is the better practice, as Dr. Simmons-Clemmons indicated in her C ertificate . -5- a court concerning compliance with or departure from standards of care may not devote annually more than 20 percent of the expert s profession al activities to activ ities that directly involve testimo ny in pers onal inju ry claims. The other applicable provision as to Drs. Konits and Imo ke s contentions is § 3-2A02(c), entitled Establishing liability of health care provider; qualifications of persons testifying, part (2)(ii)(1.), which states that any health care provider who attests in a Certificate to a defendant-health care provider s departure from the standards of care: A. Shall have had clinical expe rience, prov ided cons ultation relating to clinical practice, or taught medicine in the defe ndant s spe cialty or a related field of health care, or in the field of he alth care in which the defendant provided care or treatment to the plaintiff, within 5 years of the date of the alleged act or omission giving rise to the cause of action; and B. Except as provided in item 2 of this sub paragraph , if the defen dant is board certified in a specialty, shall be board certified in the same or a related sp ecialty as the def endant. The above-quoted language from § 3-2A-04(b)(4) and § 3-2A-02(c)(2)(ii)(1.) demonstrates the General Assembly s intent to place limitations on the qualifications of experts who attest to a defendant s breach of a standard of care and that such a breach proximately caused the plaintiff s injuries. By requiring that experts have simila r training and are board c ertified in the same field(s) as the defendant-he alth care providers a bout wh ose beha vior the exp ert is attesting, clearly, the Legislature sought to ensure that the attesting experts are q ualified to render an opinion about the defendant-health care providers alleged departure from the standards of care. The General A ssembly stated that attesting he alth care pro viders m ay not devote -6- annually more than 20 percent, shall have had clinical experience, and sh all be board certified in the same or a related specialty not that they must attest to the fact that they do not devote annually more than 20 percent, have the same clinical experience and are board certified in the same field as the defendant. I would therefore decline to hold that the General Assembly intended for such statements to be included in the Certificate and that without such statements, the claim must be dismissed on the grounds that the Cer tificate is deficie nt. We explained in Debbas v. Nelson, 389 Md. 364, 383, 885 A.2d 802, 814 (2005) that [t]he strictly limited time p eriod prov ided for se curing a va lid Certificate . . . demonstrates the General Assembly s intention that the findings and opinions contained the rein would be pre liminary. To interpret the statute oth erwise m ight effectiv ely preclude many malpractice suits from ever proceeding on the merits. Parties can instead obtain this information through discovery. As stated by the Maryland Trial Lawyers A ssociation, w hich filed an Amicus C uriae brief, a simple interrogatory would discover th e informa tion that [D r.] Konits ask s to be amended into § 3-2A-04(b), and . . ., under § 3-2A-04(b)(3)(ii), such discovery always was contemplated by the Legisla ture. See Md. C ode (19 74, 200 2 Rep l. Vol., 2006 Cum. Supp.), § 3 -2A-04( b)(3)(ii) of the Courts & Judicial Proceedings Article (stating that [d]iscovery is available as to the basis of the certificate ). As we stated in Koons Ford v. Lobach, 398 Md. 38, 62-63, 919 A.2d 722, 737 (2007): If [the Legislature] intended otherwise, then it certainly had, and still has, the ability to say so. As we have previously explained, how ever, -7- [i]t is not the task of the Judiciary to re-write th e Statute . . . . The court s charge in interpreting a statute is to determine the intent of the Le gislature, not to insert language to change the meaning of a statute. Walzer, 395 Md. at 584-85, 911 A.2d at 439-4 0 (citatio ns omi tted). I would conclude that the information regarding the attesting expert s professional attributes is not required to be contained in the Ce rtificate. That is, a claimant can get into court without it; how ever, I stress that it would be the better practice to include such information in the Certifica te so that claim ants can avoid unnecessary challenges to the qualifications of the person who submitted the docume nt. Moreo ver, if the attestin g health car e provider f ails to meet these statutory professional requirements, it would appear that the claimant is not arbitrating in good faith,3 as is requir ed. Karl v. D avis, 100 Md. App. 42, 50, 639 A.2d 214, 218 (1994). Th e issue bef ore us in this c ase, how ever, is wh at must be in cluded w ithin the four corners of the Certificate for it to be valid, not who is qualified to attest to a Certificate. Furthermore, Drs. Konits and Imoke argue that Mrs. Carroll s purported Certificate is incomplete becau se Dr. Simmons-Clemmons did not state that her opinions are based upon a reasonable degree of medical probability. Essentially, the doctors, by this contention, raise issues of admiss ibility and reliability with regard to the Certificate. Nothing in the language 3 Claiman ts must arbitrate in good faith and a failure to do so will result in dismissal of the claim . See Karl v. D avis, 100 Md. App. 42, 50, 639 A.2d 214, 218 (1994) (stating that [t]o allow less than a leg itimate good faith attempt bef ore the [Health Care Alternative Dispute Resolution Off ice] to satisfy the mandatory condition preced ent would clearly thwart the legislative intent that all claims of medical negligence over the appropriate jurisdictional amount be fairly presented and tried before the [Health Care Alternative Dispute Resolution Office] ). -8- of the Health Ca re Malpractice Claims Statute, however, requires that such an assertion be made in the Certific ate. There e xists a test for ad mitting into evidence an expert medical opinion. See Maryland R ule 5-702 (addressing the testimony by experts at trial); Trimble v. State, 300 Md. 38 7, 404, 478 A.2d 11 43, 1151 (1986) (statin g that the pa rty seeking to elicit an opinion m ust establish th at the witness is qualified to express it and that the trial judge must decide that issue as a preliminary ma tter of law). There also exists a requirement that the expert s opinion be held to a reasonable degree of medical probability to ensure that the expert s opinio n is mo re than s pecula tion or c onjectu re. See K arl, 100 Md. App. at 5152, 639 A.2d at 219 (stating that [w]hile [an] expert opinion must be based upon more than mere specul ation, it need not be expressed with absolute certainty . . . . We have required expert opinions to be establishe d within a re asonable degree of probability. ) See also Fink v. Steele, 166 Md. 354, 363 , 171 A. 49, 53 (19 34); Charlton Bros. Transportation v. Garrettson, 188 M d. 85, 94 , 51 A.2 d 642, 6 46 (19 47). Drs. Konits and Imoke also construe this Court s holding in Walzer v. Osborne, 395 Md. 563, 911 A.2d 427 (2006), to mean th at, in all circums tances, two separate do cuments must be filed - a Certificate and an attesting exp ert report, and that, because Dr. SimmonsClemmons filed only one docume nt, it is deficient. The Court said in Walzer that the expert s report must be attached to the Certificate. We based that conclusion on our reading of the statutory language of § 3-2A -04(b)(3)(i) that [t]he attorney representing each party, or the party proceeding pro se, shall file the appropriate certificate with a report of the attesting -9- expert attached (emp hasis ad ded). In this case, M rs. Carroll failed to attach a separate d ocument, an attesting exp ert report, to the Certific ate that she submitted to the Health Care Alternative Dispute Resolution Office. Notwithstanding, as clarification of our decision in Walzer, and in response to the appellees contention in this case, while it is clear that the Legislature intended for the attesting expert report to be attached to the Certificate, consistent with that statutory mandate, I see no reason why both documents may not comp rise separate parts of a single document and thereby beco me incorp orated into o ne docum ent, just as a rep ort attached to the Certificate, at the time of the initial filing, would be a complete certification.4 The Legislature s intent in enacting the Health C are Malpractice Claims Statute was to weed out non-meritorious claims by requiring claimants to submit certain information to the Health Care Alternative Dispute R esolution O ffice. The re is no reaso n why an a ttesting expert report, or Certificate, if filed with the intent to incorporate a previously filed report or Certificate, or a Certifica te containing a section tha t includes the attesting exp ert s report, is not a comple te certification o f merit, just as a report attach ed to the C ertificate wo uld be a complete certification. The essence of the statutory requirement is that the Certificate is not comp lete unle ss there i s a timely c ertificatio n and re port file d in the H ealth C laims ca se. 4 In those cases where a C ertificate is filed and su bsequen tly there is filed in the case, a report to supplement the Certificate, the subsequent filing o f a report may be made for the express purpose o f comple ting the Certificate and thereby incorporating the report as an attachmen t to the previously filed Certificate. To avoid dismissal of the underlying claim, howe ver, the s ubseq uent filin g must be time ly. -10- As the majority points out, we explained in Walzer, 395 Md. at 583, 911 A.2d at 43839, that the attesting expert report must explain how or why the physician failed or did not fail to meet th e standard of care and in clude som e details supporting the certificate of qualified expert . . . . Accor ding ly, the expert repo rt should contain at least some additional information and should supplement the Certificate. Requiring an attesting expert to provide details, explaining how or why the defendant doctor allegedly departed from the standards of care, will help weed ou t non-meritorious claims and assist the plaintiff or defend ant in evaluating the merit of the health claim. ... In Walzer, 395 M d. at 568, 91 1 A.2d a t 430, the attestin g physician state d simply that: Based on my training, expertise and review of the records, it is my opinio n that there were deviations from the standard s of care an d said deviations were the p roximate re sult of Claim ant Keith Osbo rne s inj ury. In that case, the attesting physician failed to include any information about how the physician deviated from the standard of care and how the said deviations from th e standard of care caused Mr. Osb orne s inj ury; we theref ore held tha t the Certifica te was de ficient beca use it lacked the in formation that would have con stituted an attestin g expert rep ort. In this case, Dr. Simmons-Clemmons included enough information, in accordance with Walzer, within the four corners of he r Certificate, thereby su pplemen ting the certific ation consis tent with the statutory requirements of § 3-2A-04(b) and § 3-2A-04(b)(3)(I). Although, for purposes of clarity, she could have titled the document, Certificate of Qualified Expe rt and R eport, it amounts to our exalting form over substance to invalidate the Certificate because of that -11- omission. In addition to stating that Drs. Konits and Imoke breached the applicable standard of care and that their breach caused M rs. Carroll s injuries, Dr. Simmons-Clemmons stated that the physicians failed to comm unicate eff ectively with M rs. Carroll, rega rding the tim ely removal of the catheter, and that the physicians failed to remove the ca theter in a time ly manner. She explained that Mrs. Ca rroll received treatment that fell below the standard of care in regards to removal of the Hickman catheter after chemotherapy. I w ould therefore conclude that Dr. Simmons-Clemmons successfully satisfied, within one document, the statutory requirements of the Ce rtificate and a ttesting expe rt report, as exp licated by this Court in Walzer. I would also reject Drs. Konits and Imoke s contention that the Certificate must be a formal document, and not in letter form, as w as the case h ere. Now here in the H ealth Care Malpractice Claims Statute does it require that the attesting expert s affirmations be contained in a form al docum ent; the statute sim ply requires that the attesting health care provider specifically identify the health care provider about whom he or she is speaking, and that the certifying health care provider attest to the other h ealth care provider s departure from the standard of care and that such a departure proximately caused the plaintiff s injuries. I respectfully dissent. Chief Judge Bell autho rizes me to state that he joins the views expressed in this dissent. -12-
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