          United States Court of Appeals
                      For the First Circuit

No. 13-2109

                         SANTOS RAMIREZ,

                      Plaintiff, Appellant,

                                v.

                      CAROLINA DREAM, INC.,

                       Defendant, Appellee.


          APPEAL FROM THE UNITED STATES DISTRICT COURT
                FOR THE DISTRICT OF MASSACHUSETTS

          [Hon. Rya W. Zobel, U.S. District Judge]



                              Before

                    Howard, Stahl and Lipez,
                         Circuit Judges.



     Matthew Viveiros, with whom Hunt & Viveiros, LLC was on brief,
for appellant.
     Joseph A. Regan, with whom Sean P. Scanlon and Regan & Kiely
LLP were on brief, for appellee.



                          July 28, 2014
           LIPEZ,   Circuit   Judge.        Appellant        Santos    Ramirez,    a

seaman, became ill while working aboard a fishing vessel and was

immediately hospitalized when he returned to shore.                         Shortly

thereafter, he was diagnosed with aplastic anemia, a serious blood

condition that prevented him from returning to work as a seaman. He

subsequently   brought    this     personal   injury        action    against    his

employer, seeking a remedy under the Jones Act, 46 U.S.C. § 30104,

and general maritime law.           The district court granted summary

judgment for the defendant, Carolina Dream, Inc., on each of

appellant's    alleged    causes     of    action.      On     appeal,      Ramirez

challenges only dismissal of his maritime claim for maintenance and

cure, arguing that he is entitled to that remedy until he reaches

"maximum medical recovery." Vaughan v. Atkinson, 369 U.S. 527, 531

(1962). Because we agree that the record would permit a factfinder

to find that appellant is entitled to maintenance and cure, we

vacate   the   district    court's     ruling    and    remand        for   further

proceedings.

                                      I.

A. Factual Background

           In recounting the facts, which we present in the light

most   favorable    to   appellant    Ramirez,       see,    e.g.,     Adamson    v.

Walgreens Co., 750 F.3d 73, 76 (1st Cir. 2014), we borrow liberally

from the district court's clear and succinct recitation.




                                      -2-
               Ramirez had been a crew member on the commercial fishing

boat F/V DEFIANT for about eight years when, in December 2008,

rough seas during a scallop fishing trip off the New Jersey coast

bounced the vessel and caused him to strike his jaw against his

bunk.       He sustained a laceration inside his mouth, felt dizzy the

next day, and began to feel weak and sick to his stomach about

three days after the incident.         Although appellant asked to be

brought ashore, the captain refused and instructed him to perform

his duties until the end of the trip.

               Appellant's condition worsened before the vessel returned

to its home port in Seaford, Virginia, several days later, and his

wife took him directly from the dock to a hospital emergency room

for treatment.       He remained hospitalized for about a month, was

discharged in mid-January 2009, but then was readmitted to a

different hospital a week later because of continuing symptoms.1

He was then diagnosed with aplastic anemia, "[a] rare and serious

condition" that occurs when the body stops producing sufficient new



        1
       The district court noted appellant's assertion that he was
admitted to the first hospital "due to a serious infection,"
although none of the medical reports submitted in this case
explicitly identify his problem as an infection.        Appellant's
records from the first hospital, the Sentara Careplex Hospital in
Hampton, Virginia, were not introduced in the district court,
although two documents reporting his treatment at that hospital are
included in his appendix on appeal. Reports from doctors at the
second facility, the Medical Center of Virginia Commonwealth
University in Richmond, focused on his blood disorder. In reaching
our decision, we have not relied on the records submitted for the
first time on appeal.

                                    -3-
blood cells. See Mayo Clinic Staff, "Aplastic Anemia, Definition,"

http://www.mayoclinic.org/diseases-conditions/aplastic-

anemia/basics/definition/con-20019296 (last visited July 9, 2014).

             One of appellant's treating doctors reported that the

exact cause of appellant's disease would likely remain unknown --

"as is the case in many occurrences of aplastic anemia" -- but the

doctor noted his history of hepatitis C, a typical "culprit of

aplastic anemia."       Before the trip during which he became ill,

appellant had experienced no symptoms and "was doing [his] work

well."   Ramirez states in his brief that he continues to undergo

treatment for aplastic anemia and remains unable to work.

             Ramirez   filed   this   action   in   August    2011   alleging

negligence under the Jones Act, 46 U.S.C. § 30104, and maritime

claims of unseaworthiness and maintenance and cure.               He asserts

that his injury "and the delay in receiving the proper medical

treatment" caused "a serious infection that lead to [a]plastic

[a]nemia."      In opposing summary judgment, he averred that a

factfinder could reasonably infer "manifestation of [his] aplastic

anemia during his service to the FV DEFIANT."                As noted above,

appellant on appeal has challenged only the summary judgment for

Carolina Dream on his cause of action for maintenance and cure. We

thus limit our analysis to that claim.




                                      -4-
B. The Doctrine of Maintenance and Cure

          The owner of a vessel has a duty to pay maintenance and

cure to a seaman "who [is] injured or fall[s] ill while 'in service

of the ship.'" Whitman v. Miles, 387 F.3d 68, 72 (1st Cir. 2004)

(quoting LeBlanc v. B.G.T. Corp., 992 F.2d 394, 396 (1st Cir.

1993)); see also Atl. Sounding Co. v. Townsend, 557 U.S. 404, 413

(2009); Vaughan, 369 U.S. at 531.2          "Maintenance" refers to the

cost of food and lodging during the period of illness or recovery

from injury, and "cure" covers the reasonable medical expenses

incurred for the seaman's treatment.         Atl. Sounding, 557 U.S. at

413; Whitman, 387 F.3d at 71.

          The   remedy   of   maintenance    and   cure   is   deliberately

expansive, see Vella v. Ford Motor Co., 421 U.S. 1, 4 (1975)

(noting the "breadth and inclusiveness of the shipowner's duty"),

and it is not "restricted to those cases where the seaman's

employment is the cause of the injury or illness," Calmar S.S.

Corp. v. Taylor, 303 U.S. 525, 527 (1938) ["Taylor"].                "[T]he

obligation can arise out of a medical condition such as a heart


     2
       The requirement that a seaman be "serving the ship" at the
time of his illness or injury, Lewis v. Lewis & Clark Marine, Inc.,
531 U.S. 438, 441 (2001), means that he must be "generally
answerable to its call to duty rather than actually in performance
of routine tasks or specific orders." Farrell v. United States,
336 U.S. 511, 516 (1949). Hence, a seaman who is injured or taken
ill while off the ship may nonetheless be eligible for maintenance
and cure. Cf. Haskell v. Socony Mobil Oil Co., 237 F.2d 707, 709-
10 (1st Cir. 1956) (distinguishing between brief shore leaves and
"protracted vacations" in holding that maintenance and cure is
inapplicable to the latter).

                                  -5-
problem,    a      prior   illness    that   recurs     during      the    seaman's

employment,     or    an   injury    suffered   on    shore."       1     Thomas    J.

Schoenbaum, Admiralty & Maritime Law § 6-29, at 380 (4th ed. 2001);

see also Haskell v. Socony Mobil Oil Co., 237 F.2d 707, 709 (1st

Cir. 1956) ("[I]t arises when [the seaman] is taken ill from

whatever cause during a voyage.").

            The doctrine is "so broad" that the seaman's "negligence

or acts short of culpable misconduct . . . will not relieve the

shipowner     of     the   responsibility."          Vella,   421       U.S.   at    4

(alterations omitted) (internal quotation marks omitted); see also

Messier v. Bouchard Transp., 688 F.3d 78, 82 (2d Cir. 2012) (noting

that maintenance and cure "is a far more expansive remedy" than

workers' compensation); DiBenedetto v. Williams, 880 F. Supp. 80,

86 (D.R.I. 1995) ("[M]aintenance and cure may still be awarded

plaintiff notwithstanding a pre-existing condition as long as that

condition is not deliberately concealed and is not disabling at the

time the seaman signs on for the voyage.").             The wide scope of the

duty springs from the status of seamen as "emphatically the wards

of the admiralty," Harden v. Gordon, 11 F. Cas. 480, 485 (C.C.D.

Me. 1823) (No. 6,047) (Story, J.), and advances multiple purposes,

among them to protect seamen "from the hazards of illness and

abandonment while ill in foreign ports" and to induce maritime

employers to guard against safety and health risks.                     Taylor, 303

U.S. at 528 (citing Harden, 11 F. Cas. at 483).


                                       -6-
           The shipowner's ancient duty to provide
           maintenance and cure for the seaman who
           becomes ill or is injured while in the service
           of the ship derives from the "unique hazards
           (which) attend the work of seamen," and
           fosters the "combined object of encouraging
           marine commerce and assuring the well-being of
           seamen." . . . [The shipowner's duty] "has
           few   exceptions   or   conditions    to   stir
           contentions,   cause    delays,   and    invite
           litigations."

Vella, 421 U.S. at 3-4 (quoting Aguilar v. Standard Oil Co., 318

U.S. 724, 727 (1943); Farrell v. United States, 336 U.S. 511, 516

(1949)).

           The duty of maintenance and cure applies until the seaman

has fully recovered or is "so far cured as possible," Farrell, 336

U.S. at 518 -- the latter alternative taking into account that the

seaman's condition might stabilize short of full health.           The

obligation to pay maintenance and cure is thus described as

extending until the seaman "reaches maximum medical recovery."

Vaughan, 369 U.S. at 531; see also, e.g., Haskell, 237 F.2d at 709

(explaining that "cure" is "cure in the sense of care until medical

science can do no more"); Robert Force, Federal Judicial Center,

Admiralty & Maritime Law 94 (2d ed. 2013) (defining the cutoff

point as "when the condition is cured or declared to be incurable

or of a permanent character").

           With these legal principles in mind, we now examine the

district   court's   conclusion   that   appellant   did   not   adduce

sufficient evidence to support a claim for maintenance and cure.


                                  -7-
                                II.

           Summary judgment is appropriate only if the record shows

no genuine dispute of material fact and the moving party is

entitled to judgment as a matter of law.    Fed. R. Civ. P. 56(a);

Hicks v. Johnson, No. 13-1741, 2014 WL 2793806, at *2 (1st Cir.

June 20, 2014).     Our review of the district court's grant of

summary judgment is de novo.   Hicks, 2014 WL 2793806, at *2.

           Appellant asserts that he is entitled to maintenance and

cure until he has reached maximum recovery from aplastic anemia,

which he contends has not yet occurred.         The district court

rejected his entitlement to any maintenance and cure on the ground

that appellant failed to produce evidence that the disease arose

during his service on the F/V DEFIANT -- "[o]ther than asserting

that he was in 'normal health' prior to the fishing voyage and

hospitalized upon returning to port."       The court's rationale

reflects a too-narrow view of both the facts and the vessel owner's

responsibility.

           As detailed above, appellant began feeling weak and dizzy

shortly after he sustained an injury onboard the F/V DEFIANT, and

he required more than a month's hospitalization immediately after

disembarking.   A doctor's report stated that he was admitted to a

second hospital "due to continued symptoms" a week after he was

initially discharged, at which time he was diagnosed with aplastic

anemia.   Hence, the record shows that appellant became ill during


                                -8-
the December 2008 fishing voyage and remained ill continuously

through the time he was determined to have the blood condition.

Before that voyage, appellant had been working regularly and

without symptoms, notwithstanding a history of hepatitis C.

          As appellant emphasizes, the facts here resemble those

considered by the Supreme Court in Taylor.      In that case, a seaman

who obtained medical treatment after stubbing his toe in the ship's

boiler room was diagnosed with Buerger's disease, an incurable

illness that affects the arteries and veins.     303 U.S. at 526.   The

Court took for granted that the seaman was entitled to maintenance

and cure even though the disease was found to be unrelated to the

foot injury.   See id. at 528-29.       The Court focused, instead, on

the duration of the duty.   It noted widespread recognition that a

seaman who is hurt or becomes ill while serving the ship may

receive maintenance and cure "for a reasonable time after the

voyage," but it acknowledged that most cases so holding involved a

work-related disability.    Id.

          The Court nonetheless held that the right to maintenance

and cure "may outlast the voyage" even when "the efficient cause of

the injury or illness was [not] some proven act of the seaman in

the service of the ship."   Id. at 529.      Among its rationales, the

Court invoked "the liberality" that admiralty courts give to rules

"devised for the benefit and protection of seamen who are its

wards," and it noted the undesirable consequences of a contrary


                                  -9-
conclusion: "The practical inconvenience and attendant danger to

seamen in the application of a rule which would encourage the

attempt   by     master   or   owner   to     determine   in   advance    of   any

maintenance and cure, whether the illness was caused by the

employment, are manifest."        Id. at 529-30.

               The Supreme Court thus confirmed that maintenance and

cure is available for a disabling illness whether or not that

illness, though discovered during treatment for an onboard injury,

resulted from the injury.         Moreover, as noted above, it does not

matter    if    an   incapacitating    illness     preexisted    the     seaman's

maritime employment, so long as the condition was not deliberately

concealed or disabling when the seaman joined the ship's service.

See Messier, 688 F.3d at 84; Schoenbaum, supra, at 380.                        The

inquiry is not one of causation, but of timing: did the illness for

which the seaman seeks maintenance and cure begin or become

aggravated while he was "serving the ship"? Lewis v. Lewis & Clark

Marine, Inc., 531 U.S. 438, 441 (2001).3            Here, then, the question

for purposes of summary judgment is whether a factfinder could




     3
       The Court in Taylor went on to consider the proper duration
for the maintenance-and-cure duty in such instances and settled on
the now well established principle of maximum medical recovery.
See 303 U.S. at 530 ("We can find no basis for saying that, if the
disease proves to be incurable, the duty extends beyond a fair time
after the voyage in which to effect such improvement in the
seaman's condition as reasonably may be expected to result from
nursing, care, and medical treatment.").

                                       -10-
conclude that Ramirez suffered from aplastic anemia while still in

service to the FV/DEFIANT.

          The   facts   outlined    above   readily   permit   such   an

inference.   Ramirez presented evidence that he boarded the ship

feeling well and able to work, but left very ill.          His medical

history includes a known trigger for aplastic anemia.          Given his

deteriorating health while in the ship's service, his history of

hepatitis C, and the short interval between the onset of illness

and the diagnosis, a factfinder reasonably could conclude that the

dizziness and weakness that appellant experienced on the vessel

were the first noticeable and debilitating symptoms of the aplastic

anemia.   Although the record does not contain medical evidence

substantiating appellant's contention that the delay in treatment

for his mouth laceration caused "a serious infection" that in turn

triggered the aplastic anemia, he is not obliged to prove a cause-

and-effect medical basis for the disease.     See Taylor, 303 U.S. at

527. Rather, as we have explained, the duty to pay maintenance and

cure "arises when [the seaman] is taken ill from whatever cause

during a voyage."   Haskell, 237 F.2d at 709.

          Moreover, in keeping with the breadth of the duty to

provide maintenance and cure, the Supreme Court has stated that, in

evaluating the shipowner's liability, "ambiguities or doubts . . .

are resolved in favor of the seaman."       Vaughan, 369 U.S. at 532.

At a minimum, a factfinder could conclude on the record before us


                                   -11-
that aplastic anemia was the most likely reason for appellant's

deteriorating       condition    while    on    the    ship,   with      the   disease

manifesting as a result of the injury to appellant's jaw or

happening to coincide with the injury.

              Our decision in Whitman v. Miles, cited by the district

court, is not to the contrary.              The plaintiff in that case was

diagnosed with multiple sclerosis ("MS") after experiencing various

physical symptoms (including fatigue, numbness, and incontinence)

while working as a cook on a ship.              The vessel owner conceded his

general duty to provide maintenance and cure, but the parties

disputed the duration of the duty and its application to the

seaman's specific treatment for depression. See 387 F.3d at 71-74.

              We declined to determine whether the depression was a

symptom of MS or a separate ailment because, regardless, the seaman

would not be entitled to maintenance and cure based on that

disorder. Id. at 74. We explained that, if depression were viewed

as a distinct ailment, it did not provide a basis for maintenance

and cure because the seaman had "failed to produce any evidence

that she began to suffer from depression while in the service of

the ship."     Id.    Alternatively, if the depression were treated as

a   symptom    of    MS,   she   would     have       no   claim   for    additional

compensation because the employer already had paid maintenance and

cure up to the point of maximum medical recovery.                     Id.; see also

id. at 72 ("The testimony of the doctors for both parties leaves no


                                         -12-
genuine issue of material fact that [the plaintiff's] treatment

. . . would not reverse her symptoms or improve her condition

beyond the point of maximum medical recovery.").

           Thus, in Whitman, the maintenance and cure claim that we

rejected for evidentiary insufficiency involved either a second,

possibly   separate    medical    condition   or    an   attempt   to   extend

benefits beyond the previously identified cutoff point for the

remedy.    Here, by contrast, the recognized triggers for aplastic

anemia, together with the evidence of physical symptoms experienced

by appellant onboard the vessel, provide sufficient support for a

finding that his aplastic anemia arose or became aggravated during

his   service   on   the   ship   and,   hence,    triggered   the   duty   of

maintenance and cure.

           The impact of our decision, however, may be modest.              At

oral argument, appellant's counsel reported that appellee Carolina

Dream paid maintenance and cure to his client through the date of

the district court's summary judgment ruling in August 2013. As we

have explained, appellant is entitled to maintenance and cure only

while he is "moving toward recovery," In re RJF Int'l Corp. for

Exoneration from or Limitation of Liab., 354 F.3d 104, 106 (1st

Cir. 2004), up to the point of "maximum medical recovery," Vaughan,

369 U.S. at 531.      Although Ramirez asserts that his condition has

not yet stabilized, the record on that issue is undeveloped and our

decision here does not foreclose summary judgment on the ground


                                    -13-
that the employer has satisfied its obligation.         We note, however,

that even after achieving maximum medical cure, a seaman may

"reinstitute a demand for maintenance and cure where subsequent new

curative medical treatments become available."          Force, supra, at

94; see also Farrell, 336 U.S. at 519 (noting that the seaman may

be able to recover, "in a new proceeding," the costs of "future

treatment   of   a   curative   nature"   and   "for   maintenance   while

receiving it"); Messier, 688 F.3d at 82 (quoting Force and citing

Farrell).

            Accordingly, we remand this case to the district court

for further proceedings consistent with this opinion.

            So ordered.




                                   -14-
