
USCA1 Opinion

	




                            UNITED STATES COURT OF APPEALS                                FOR THE FIRST CIRCUIT                                 ____________________          No. 96-1429                               LINDA M. DANIELS-RECIO,                                Plaintiff - Appellee,                                          v.                         HOSPITAL DEL MAESTRO, INC., ET AL.,                               Defendants - Appellants.                                 ____________________          No. 96-1686                               LINDA M. DANIELS-RECIO,                                Plaintiff - Appellant,                                          v.                         HOSPITAL DEL MAESTRO, INC., ET AL.,                               Defendants - Appellees.                                 ____________________                    APPEALS FROM THE UNITED STATES DISTRICT COURT                           FOR THE DISTRICT OF PUERTO RICO                 [Hon. Raymond L. Acosta, Senior U.S. District Judge]                                          __________________________                                 ____________________                                        Before                               Torruella, Chief Judge,                                          ___________                     Coffin and Campbell, Senior Circuit Judges.                                          _____________________                                _____________________               Mario Pab n-Rosario, with  whom Jos  Luis  Gonz lez-Casta er               ___________________             ____________________________          and  Law Offices of Jos  Luis Gonz lez-Casta er were on brief for               __________________________________________          appellant SIMED.               Kevin  G. Little, with whom  Law Offices David  Efr n was on               ________________             ________________________          brief for Linda Daniels-Recio.               Edgardo A. Vega-L pez, with  whom Jim nez, Graffam & Lausell               _____________________             __________________________          was on  brief for  Asociaci n Hospital  del Maestro and  Evanston          Insurance Company.                                 ____________________                                    March 28, 1997                                 ____________________                                         -2-                    TORRUELLA,  Chief  Judge.    On June  24,  1992,  Linda                    TORRUELLA,  Chief  Judge.                                ____________          Daniels-  Recio  ("Daniels")  filed a  medical  malpractice  suit          against Dr. Rafael S nchez-Monserrat  ("S nchez") and  Asociaci n          Hospital del  Maestro ("AHDM"),  a hospital  in San Juan,  Puerto          Rico.   On November 2, 1992, Daniels amended her complaint to add          Dr. S nchez'   insurer,  Sindicato   de   Aseguradores  Para   la          Suscripci n  Conjunta de  Seguros de  Responsibilidad Profesional          M dico  Hospitalaria  ("SIMED"),  and  AHDM's  insurer,  Evanston          Insurance Company  ("Evanston"), as  defendants.  On  January 17,          1995, AHDM and  Evanston filed a motion for summary judgment.  On          March 30,  1995, the district  court granted AHDM  and Evanston's          motion for summary judgment.                    In  the meantime, on February  3, 1995, Daniels filed a          motion  in  limine  seeking   determination  of  coverage   under          Dr. S nchez' insurance  policy with SIMED.  On February 28, 1996,          the district court determined that Daniels'  claim was covered by          Dr.  S nchez' policy, which had a  stated limit of $500,000.  The          case  was scheduled  for trial.   On March 15,  1996, following a          settlement  conference, Daniels,  Dr.  S nchez and  SIMED entered          into  a  Stipulation  Agreement  whereby  they  agreed  that  the          district  court would  enter  final judgment  for Daniels  in the          amount  of $500,000  in order  for SIMED  to appeal  the district          court's determination of policy coverage.                    We  have  before  us  SIMED's  appeal  from  the  final          judgment,  based  on  the  district  court's allegedly  erroneous          determination  regarding policy  coverage,  as well  as  Daniels'                                         -3-          appeal  from the  district court's entry  of summary  judgment in          favor of AHDM and Evanston.  We affirm.                                      BACKGROUND                                      BACKGROUND                    As our review  of the district court's grant of summary          judgment is de novo, we present the background facts in the light                      __ ____          most   favorable  to   the  nonmovant,  drawing   all  reasonable          inferences  in her  favor.   Dubois  v.  United States  Dep't  of                                       ______      ________________________          Agriculture, 102 F.3d 1273, 1283-84 (1st Cir. 1996).          ___________                    In May  1989, after being admitted  to AHDM's emergency          room,  Daniels was referred by AHDM staff to Dr. Regis-Bonilla, a          pneumologist at Cl nica Las Am ricas.  Daniels received treatment          from Dr.  Regis-Bonilla for approximately nine  months, before he          moved his practice to another city.  After Dr. Regis-Bonilla left          his  San Juan practice,  Dr. S nchez joined  Cl nica Las Am ricas          and began treating Daniels.  In early 1990, Dr. S nchez diagnosed          Daniels' condition as "silent asthma."                    On  August 31, 1990, Daniels was again admitted to AHDM          on  an emergency basis.  She was hospitalized until September 17,          1990.    During  this  hospitalization,  Dr.  S nchez  prescribed          Medrol, an adrenocortical steroid, for  the first time.  Extended          use of this medication  can cause a number of  adverse reactions,          including  hypertension,  muscle   weakness,  steroid   myopathy,          osteoporosis, spinal compression fractures, abdominal distention,                                         -4-          development of a Cushingoid  state,1 and manifestations of latent          diabetes mellitus.                    Daniels  was again  admitted  to AHDM  on an  emergency          basis on October 5, 1990.  After a consultation, Dr. S nchez took          over as  Daniels' primary attending physician.   Hospital records          showed  that Daniels had been  taking Medrol since  her August 31          admission  and that she had steroid myopathy as a complication of          the steroid  treatment.   Daniels was discharged  on November  1,          1990.                    On December 17, 1990, Daniels yet again was admitted to          AHDM.     Daniels  had   been  taking   Medrol  since   her  last          hospitalization and  continued to  take it throughout  this stay.          Steroid  complications,  specifically  steroid-induced  diabetes,          were  noted in her records.   Daniels was  discharged on December          31,  1990, with records showing that her "asthma" continued to be          active and that she was taking Medrol upon her discharge.                    On May 30,  1991, Daniels  was admitted to  AHDM for  a          fifth  time.   She was  still taking  Medrol at  the time  of her          admission and  was continued on the medication  during the course          of her hospitalization.   Several steroid  related complications,          including  Cushing's  syndrome, osteoporosis,  spinal compression          fractures, hypertension, and  a decrease in height, were noted at          the time of her admission.  She was discharged on June 28, 1991.                                        ____________________          1  Cushing's Syndrome is characterized  by mood phases, excessive          hair growth,  increased bruisability, peripheral  muscle atrophy,          the  formation of  a pot  belly and the  formation of  a "buffalo          hump" on the afflicted person's back.                                         -5-                    During  each hospitalization,  a series  of respiratory          function  tests were  run  on  Daniels.    None  of  these  tests          indicated that she was having respiratory difficulty.                    Upon her last  discharge, on June 28, 1991, Daniels was          referred  by  Dr.  S nchez  to  the  National Jewish  Center  for          Immunology and Respiratory Medicine ("National Jewish Center") in          Denver, Colorado.   Dr.  S nchez' referral letter  indicates that          Daniels had been prescribed Medrol for the previous twelve months          and that she was suffering from complications related to extended          corticosteroid  usage.  On August 26, 1991, Daniels had her first          appointment at National Jewish Center.  At the time of this first          visit,  the  staff  at  National Jewish  Center  questioned  both          Dr. S nchez' diagnosis of "silent  asthma" and his treatment with          Medrol for  at least a year.  The staff at National Jewish Center          tapered  Daniels'  Medrol dosage  and gave  her  a final  dose on          September  3, 1991, the day  she was admitted  to National Jewish          Center.    Doctors there  discovered  that  her osteoporosis  had          developed  to such an extent that her bone mass was approximately          70%  of the  normal  level.   The  National Jewish  Center  staff          diagnosed  Daniels  as  suffering  from   breathing  difficulties          secondary to  an anxiety disorder.   Daniels was  discharged from          National Jewish Center on September 21, 1991.                    Daniels'  experts  indicated  that  the   diagnosis  of          "silent asthma"  was, at least ultimately, incorrect based on the          objective respiratory test results.   They further stated  that a          course  of  Medrol treatment  extending  beyond  two weeks  would                                         -6-          certainly  result  in  the severe  complications  experienced  by          Daniels.                                      DISCUSSION                                      DISCUSSION                    In  this   diversity   case,  we   apply  Puerto   Rico          substantive law.   See Erie R.R. Co. v. Tompkins, 304 U.S. 64, 92                             ___ _____________    ________          (1938);  Carota v. Johns Manville  Corp., 893 F.2d  448, 450 (1st                   ______    _____________________          Cir. 1990).          I.  Policy Coverage          I.  Policy Coverage                    SIMED  issued to  Dr. S nchez  a "claims  made" medical          malpractice  insurance policy  effective  from July  7, 1991,  to          July 7,  1992.   This policy  limited liability  to $500,000  per          "medical incident"  that occurred during the  period of coverage,          up to  an  aggregate  of  $1,000,000.   The  policy  also  had  a          retroactive  component, which  provided coverage  to  Dr. S nchez          from July  2, 1986 to July  7, 1991.  The  retroactive portion of          the policy  provided coverage of $100,000  per "medical incident"          that occurred during the retroactive period of coverage, up to an          aggregate  of $300,000.    The question  presented  below and  on          appeal is when Daniels'  "medical incident" occurred, which would          determine which policy, and coverage limit, applied.                    SIMED claims  the district  court erred by  determining          that Daniels'  "medical incident" spanned the  coverage period of          both policies2 and, thus,  that Daniels' claim is covered  by the                                        ____________________          2  The policy language states:               The  Syndicate will pay on behalf  of the Insured, with               respect only to his practice within the Commonwealth of               Puerto Rico:                                         -7-          subsequent policy, whose liability limit is $500,000.  We find no          error in the district court's determination.                    The  policy  language, including  the  language  of the          amendment,  as set out in the margin, ties policy coverage to the          timing of medical incidents.3  The district court properly framed          the issue as follows:                    if the incident transcended the period of the                    lower  policy  coverage,   that  is,  if  Dr.                    S NCHEZ MONSERRAT'S rendering of,  or failure                    to  render   professional  services  extended                    beyond the July 7, 1991 date, then the higher                    coverage  would apply because all his acts or                    omissions, when taken together,  comprise one                                        ____________________               All  sums  which  the   Insured  shall  become  legally               obligated to pay as damages because of injury  to which               this policy applies caused by medical incident . . . .          Medical incident is defined as:               [A]ny  act or  omission  . .  .  in the  furnishing  of               professional  medical .  . .  services by  the Insured.               Any  such act  or omission,  together with  all related               acts or omissions in the furnishing of such services to               any  one  person   shall  be  considered   one  medical               incident.          The Retroactive  Date Amendment Endorsement II,  which deals with          retroactive  insurance coverage  in  the amount  of $100,000  per          medical incident, states:               Irrespectively of the  retroactive date and  the limits               of  liability shown  in  the Declarations  Page of  the               above numbered  policy, in consideration of the payment               of  the above stated  premium, claims arising  out of a               medical incident which occurred  between 7-02-86 and 7-               07-91 will be covered by this policy subject to a limit               of liability  of $100,000  per medical incident  and an               aggregate of $300,000.          3  Because the  "event" triggering policy coverage is  the timing          of the medical incident, SIMED's repeated references in its brief          to  state and federal cases  that reviewed policies  in which the          triggering event  was the  manifestation of the  injury miss  the          mark.                                         -8-                    medical  incident  pursuant  to   the  policy                    definitions.          Amended Order  Granting Plaintiff's Motion in  Limine and Setting          Trial and Pretrial Settlement Conference, Feb. 28, 1996, at 2-3.                    Title 26, section  1114, of the Puerto  Rico Civil Code          governs the  contents of insurance policies.   In accordance with          this  provision,  language  in  an  insurance  policy  is  to  be          construed according to the  "most common and usual meaning, . . .          paying  . . .  attention .  . .  to the  general use  and popular          meaning of the idioms."  Morales Garay v. Rold n Coss, 110 P.R.R.                                   _____________    ___________          909, 916 (1981).4 Moreover, "insurance contracts, being contracts          of  adhesion, are  to  be liberally  construed  in favor  of  the          insured."  Rivera  v. Insurance  Co. of Puerto  Rico, 103  P.R.R.                     ______     ______________________________          128,  131 (1974);  see also  P.R. Laws  Ann. tit.  26,    1114(2)                             ________          (Supp. 1996)  ("In the interpretation of said  policies, the text          that is of most benefit to the insured shall prevail.").                    The  district court  relied on  the following  facts in          reaching its determination that the medical incident spanned both          policies  and, therefore,  triggered coverage  of the  subsequent          policy:                       1.  Insurance Company Progressive Report                      In the Progressive Report submitted  to the                    Caribbean  American  Life Assurance  Company,                    Dr. S NCHEZ   MONSERRAT    marked   the   box                    indicating "YES" to the question posed on the                    report  which asked  "Is patient  still under                    your care for  this condition?".  He  further                    informed that she had received a consultation                    from his  office on  August 4, 1991  and that                                        ____________________          4  Page cites are to the Official Translation.                                         -9-                    she  was   at  the   time  in   Colorado  for                    "treatment."    Significantly, the  report is                    dated September 3, 1991, and is filled out in                    the doctor's own handwriting.                             2.  Pulmonary Questionnaire                      SIMED argues that the doctor's treatment of                    Ms. DANIELS ended on  June 28, 1991, the date                    of her  last hospitalization.   It  bases its                    belief   on   the   Pulmonary   Questionnaire                    prepared  by  Dr.   S NCHEZ  MONSERRAT,   for                    submission to the Social  Security Disability                    Determination Program.   This form was filled                    out  by   the  doctor  on  April   20,  1992,                    approximately   seven    months   after   the                    aforementioned    insurance     report    was                    completed.  Although  on this  questionnaire,                    the doctor indicates that  "[Ms. Daniels was]                    not  seen since  June 28,  1991",  it appears                    that  the  doctor's  statements therein  were                    made in  reference to  his last visit  to the                    plaintiff   at  the   hospital.     A  closer                    examination  of page 3  of the questionnaire,                    requesting  a listing of the office visits by                    the patient, reveals that the  last entry for                    Ms. DANIELS  was for  May 30, 1991,  the date                    that the doctor ordered  her hospitalization,                    which hospitalization concluded  on June  28,                    1991.     Thus,  noticeably   absent  is  the                    August 4,  1991,  consultation  which he  had                    disclosed in the form filled out seven months                    earlier    for    the   insurance    company.                    Furthermore, in  the aforementioned pulmonary                    questionnaire,  the   doctor  indicated  that                    Ms. DANIELS was "sent to the Jewish Institute                    of Allergy &  Immunology--Aug. 26,  1991...."                    Since  he  was  the  doctor  originating  the                    referral to the  Institute, this  affirmation                    could be construed as  another acknowledgment                    that Ms. DANIELS was still under his care and                    treatment  at that time;  clearly beyond July                    7, 1991, the higher coverage date.                          3.  Admitted Facts-Pretrial Order                      Finally, though not  less significant,  the                    parties  conceded in Part  II, Admitted Facts                    of the Proposed Joint Pretrial Order filed on                    February  2,   1995  (docket  No.   49)  that                    Ms. DANIELS  was  a  patient  of  Dr.  RAFAEL                                         -10-                    S NCHEZ  MONSERRAT  from May  21,  1990 until                    September 3, 1991.          Id. at 3-5.  We agree that these facts indicate  that Dr. S nchez          ___          continued  to perform acts or omissions related to the furnishing          of professional medical  services to Daniels after  July 7, 1991,          thus triggering the subsequent policy, which provides coverage of          $500,000 per medical incident.                                         -11-          II.  Summary Judgment          II.  Summary Judgment                    We  review  the  district   court's  grant  of  summary          judgment  de novo,  and  will uphold  that determination  "if the                    _______          record,  viewed  in the  light  most favorable  to  the nonmoving          party, shows that  'there is no genuine issue as  to any material          fact and  that the moving  party is entitled  to a judgment  as a          matter of law.'"   Continental  Ins. Co. v.  Arkwright Mut.  Ins.                             _____________________     ____________________          Co., 102 F.3d 30, 33 n.4 (1st Cir. 1996) (quoting Fed. R. Civ. P.          ___          56(c)).  Faced  with a properly documented  motion, the nonmovant          must  establish the existence of a genuine issue of material fact          in order to avoid  the entry of an adverse judgment.   Garside v.                                                                 _______          Osco Drug, Inc., 895 F.2d 46, 48 (1st Cir. 1990).          _______________                    Daniels attacks the  district court's grant  of summary          judgment on various grounds, which we will consider in turn.                    A.  Obvious malpractice                    A.  Obvious malpractice                    Dr. S nchez'  AHDM personnel  records indicate  that he          maintained hospital privileges during the course of his treatment          of Daniels.   Under  Puerto Rico  law, a  hospital's relationship          with doctors  to whom  it  grants hospital  privileges must  meet          several requirements.  The  obligation that Daniels suggests AHDM          failed  to meet  here,  such  that  AHDM  would  be  jointly  and          severally liable for Dr. S nchez' malpractice, requires hospitals          to monitor the work of  physicians with hospital privileges,  and          to  intervene when  possible in  the face  of an  obvious  act of          medical malpractice.   See M rquez Vega  v. Mart nez Rosado,  116                                 ___ ____________     _______________                                         -12-          P.R.R.  489,  500 (1985);  see  also Carlos  J.  Irizarry Yunqu ,                                     _________          Responsabilidad Civil Extracontractual 253 (1996).          ______________________________________                    Beyond her conclusory  allegations to  the effect  that          Dr. S nchez' malpractice  was so  obvious that AHDM  staff should          have  intervened, Daniels  fails to  present sufficient  facts to          show that there is a "genuine issue for trial."  LeBlanc v. Great                                                           _______    _____          American Ins.  Co., 6 F.3d 836, 841-42 (1st Cir. 1993).  Although          __________________          Daniels  directs our attention to the deposition testimony of her          experts,  all of  whom agreed  that the  diagnosis of  asthma was          incorrect,  none of  this deposition  testimony raises  a genuine          issue as  to whether any act of malpractice by Dr. S nchez was so          obvious  that AHDM should have  intervened.  The  only mention of          "obviousness" in  the deposition testimony comes  from Dr. Harold          Nelson,  one  of  Daniels'  experts.    He states  that  Daniels'          osteoporosis and  her Cushingoid  state were obvious  symptoms of          excessive  corticosteroid   use.    That  the   symptoms  Daniels          exhibited after corticosteroid treatment were  the obvious result          of excessive use of  the steroid does not sufficiently  raise the          issue of whether those symptoms were the obvious result of an act          of  malpractice.   Daniels  did not  meet  her burden  of  coming          forward with concrete  facts that  would give rise  to a  genuine          issue of material fact regarding AHDM's liability.                    B.   Negligence of AHDM Staff Doctors and Nurses                    B.   Negligence of AHDM Staff Doctors and Nurses                    Daniels next  argues that  the district court  erred in          finding  that  AHDM's  doctors  did not  engage  in  malpractice.          Daniels  failed  to press  this  contention  before the  district                                         -13-          court.   Because  Daniels' Opposition  to Defendants'  Motion for          Summary  Judgment  fails  to  squarely raise  any  contention  of          specific  malpractice on  the  part of  AHDM's medical  staff, we          generally  will not  consider such  an argument  on appeal.   See                                                                        ___          Grenier v.  Cyanamid Plastics, Inc.,  70 F.3d 667,  678 (1st Cir.          _______     _______________________          1995) (recognizing that, by failing to present an argument in his          opposition  to   summary  judgment  below,  appellant  failed  to          preserve the argument for appeal).                    Moreover, her argument is  without merit.  She premises          AHDM's  liability on the opinion of her expert, Dr. Alvarez, that          AHDM  staff members  should have  questioned Dr.  S nchez' faulty          diagnosis and that, had they done so, her result would have  been          different.     Daniels   misconstrues  Dr.   Alvarez'  deposition          testimony.   Although  Dr. Alvarez  noted that  nurses frequently          question  doctors' practices  and  that it  did  not appear  that          AHDM's nurses had questioned  Dr. S nchez, immediately thereafter          Dr. Alvarez  stated  that he  had no  opinion  as to  whether the          nurses  or hospital  staff were  negligent.   This is  hardly the          forceful  evidence of negligence that Daniels makes it out to be,          and certainly does not raise a genuine issue as to whether AHDM's          staff was negligent.                    C.   Whether Dr. S nchez was an independent contractor                    C.   Whether Dr. S nchez was an independent contractor                    Daniels contends that the district court misinterpreted          our  opinion in  Su rez Matos  v. Ashford  Presbyterian Community                           ____________     _______________________________          Hosp., 4 F.3d 47 (1st Cir. 1993), when it found that AHDM was not          _____          liable because Dr. S nchez  was merely an independent contractor.                                         -14-          Daniels argues that under Su rez Matos, a hospital is liable when                                    ____________          a negligent  doctor is more  than a mere  "independent contractor          having  no other  relationship with  the hospital."   Id.  at 52.                                                                ___          Daniels  takes this quotation out of context.  The relevant quote          reads:                    While   strictly,   perhaps,  that   decision                    [M rquez Vega v. Mart nez Rosado,  116 D.P.R.                     ____________    _______________                    489,  500  (1985)] contained  dictum  that we                    might distinguish, and  certainly we need not                    adopt plaintiff[']s contention that  it would                    impose   liability  in   the   case   of   an                    independent   contractor   having  no   other                    relationship  with the hospital,  it is clear                    here that granting  staff privileges  coupled                    with  a joint  sharing in  profits,  left the                    hospital fully responsible.          Id.  The  Su rez Matos  opinion, which applies  to situations  in          ___       ____________          which the hospital has granted staff privileges to and engages in          a profit-sharing relationship with  a negligent physician to whom          it  refers  a  patient, did  not  discuss  the  situation Daniels          presents here.                    Furthermore, the situation  dealt with in Su rez  Matos                                                              _____________          was  markedly  different from  the case  before  us.   There, the          patient   sought the assistance  of the hospital  on an emergency          basis.    Id.  at 48.   The following  day, a  uterine tumor  was                    ___          removed  and was examined by a pathologist on the hospital staff.          Id.   The pathologist misdiagnosed the tumor  as benign.  Id.  By          ___                                                       ___          referring the tumor  to the  staff doctor, the  hospital was,  in          effect,  certifying the  competence  of that  doctor.   The  same          cannot  be said of  AHDM, which  did not  advise Daniels  to seek          treatment from Dr. S nchez.                                         -15-                    Daniels further  argues that Dr. S nchez  was more than          an  independent contractor of AHDM and, thus, that AHDM is liable          for  his malpractice.   Daniels  misconstrues the  application of          Puerto  Rico's independent contractor law.   In M rquez Vega, the                                                          ____________          Puerto Rico Supreme Court visited this very issue:                    Under  the  second  alternative  --  where  a                    person goes directly to a physician's private                    office, agrees with him  as to the  treatment                    he  or she is going to receive, and goes to a                    given    hospital    on    the    physician's                    recommendation     merely     because    said                    institution  is  one  of  several  which  the                    physician has the  privilege of using  -- the                    situation  is somewhat different.  Under this                    factual  framework,   the  main  relationship                    established is between the "patient"  and the                    physician, while the relationship established                    between the patient and  the hospital is of a                    supplementary and incidental nature.  In this                    case, as  a rule, the hospital  should not be                          __________                    held liable  for the exclusive  negligence of                    an  unsalaried physician,  who was  first and                    foremost entrusted with the patient's health.          116  D.P.R. at  499 (emphasis  in original);  see also  Carlos J.                                                        ________          Irizarry  Yunqu ,  Responsabilidad Civil  Extracontractual 252-53                             _______________________________________          (1996).                    Daniels admitted  in her deposition testimony  that she          relied primarily on Dr.  S nchez for her diagnosis and  treatment          and "primarily entrusted [to him] the  diagnosis and treatment of          her  respiratory condition."   Deposition of Linda Daniels-Recio,          July 26, 1993, at 113.  She  also indicated that she did not rely          on AHDM's doctors  or staff  for diagnosis and  treatment of  her          respiratory  problems.    Id.   at  113-14.    Finally,  Daniels'                                    ___          admissions  to AHDM were at  the instruction of  Dr. S nchez, who          was not a  salaried employee of AHDM.  These facts certainly fall                                         -16-          within  the scope  of the  discussion in  M rquez Vega,  and AHDM                                                    ____________          cannot  be held  liable  on a  theory  of independent  contractor          liability.5                    Having addressed  and  found lacking  all  of  Daniels'          claims  regarding  the  district  court's  direction  of  summary          judgment in AHDM's favor, we affirm.                                      CONCLUSION                                      CONCLUSION                    For  the  foregoing  reasons, we  affirm  the  district                                                      affirm                                                      ______          court's determination of policy coverage and its grant of summary          judgment in favor of AHDM and Evanston.                                        ____________________          5  Indeed,  the Puerto Rico  Supreme Court stated  that, in  this          situation, it  is not the  doctor, but the  hospital that is  the          independent contractor:               [T]he cited case [relied upon by the lower court] deals               with  the benefits  derived by  the principal  from the               work performed  by the  independent contractor.   Under               the  alternative we  are  discussing now  -- where  the               patient  first goes  to the  physician and then  to the               hospital  on  the  physician's  recommendation  --  the               physician would be the principal and the hospital would               then be the "independent contractor."          M rquez Vega, 116 D.P.R. at 499.          ____________                                         -17-
