                          This opinion will be unpublished and
                          may not be cited except as provided by
                          Minn. Stat. § 480A.08, subd. 3 (2012).

                               STATE OF MINNESOTA
                               IN COURT OF APPEALS
                                     A14-0343

                                     Randall Dahler,
                                       Appellant,

                                            vs.

                            Auto-Owners Insurance Company,
                                     Respondent.

                                Filed December 8, 2014
                                Reversed and Remanded
                                    Chutich, Judge

                               Benton County District Court
                                 File No. 05-CV-13-557

Michael A. Bryant, Bradshaw & Bryant, PLLC, Waite Park, Minnesota (for appellant)

James S. McAlpine, Garin L. Strobl, Quinlivan & Hughes, P.A., St. Cloud, Minnesota
(for respondent)

         Considered and decided by Chutich, Presiding Judge; Halbrooks, Judge; and Ross,

Judge.

                         UNPUBLISHED OPINION

CHUTICH, Judge

         Appellant Randall Dahler appeals summary judgment in favor of respondent Auto-

Owners Insurance Company. He contends that the district court erroneously found that

the injury he received in the course of medical treatment for his automobile-related injury

did not arise out of his use of an automobile and therefore was not covered by his no-fault
insurance. Because an injury directly caused by an adverse reaction to the medical

treatment of a no-fault-covered injury arises out of the use of a motor vehicle, we reverse

and remand.

                                         FACTS

       On February 24, 2009, appellant Randall Dahler went to his truck to leave for

work. Upon opening the door, Dahler placed one foot on the truck’s running board; his

other foot slipped and Dahler fell backwards on his back and buttocks. Although he went

to work, Dahler soon began to feel pain in his back and had difficulty walking. After two

months of chiropractic therapy and continued pain, Dahler was referred to his primary

physician.

       Medical imaging revealed that Dahler had a pinched nerve and inflammation in his

back. Dahler was then referred to another doctor, who recommended steroid injections to

treat his back problems. In July and August 2009, Dahler received steroid injections in

his lower back. After the injections, Dahler began experiencing symptoms of Guillain-

Barré syndrome,1 and Dahler’s primary physician diagnosed him with the disease.

       An independent medical examiner opined, to a reasonable degree of medical

certainty, that the “steroid injections that were given for [Dahler’s] back pain following



1
   “Guillain-Barré syndrome (GBS) is a rare disorder in which a person’s own immune
system damages their nerve cells, causing muscle weakness and sometimes paralysis.
[The syndrome] can cause symptoms that usually last for a few weeks. Most people
recover fully from [the syndrome], but some people have long-term nerve damage. In
very rare cases, people have died of [the syndrome], usually from difficulty breathing.”
Guillain-Barré Syndrome (GBS), Centers for Disease Control and Prevention,
http://www.cdc.gov/flu/protect/vaccine/guillainbarre.htm (last updated Nov. 24, 2014).

                                            2
the injury of February 24, 2009 were related to the back injury at that time . . . .” 2

Respondent Auto-Owners Insurance Company, with which Dahler had an auto insurance

liability policy, reimbursed him for his out-of-pocket expenses for the treatment of his

back injury, including the injections. But Auto-Owners also informed Dahler that it

would not pay any expenses for either the syndrome or missed work related to the

syndrome under Dahler’s no-fault policy.

       In June 2012, Dahler sued Auto-Owners.           Dahler alleged that the medical

expenses arising out of the treatment of the syndrome should be covered by his no-fault

insurance.

       Auto-Owners moved for summary judgment, arguing that the syndrome did not

arise from the use or maintenance of an automobile and therefore was not covered under

Minnesota Statutes section 65B.44 (2012) of the Minnesota No-Fault Automobile

Insurance Act (no-fault act). For purposes of the summary-judgment motion only, the

parties agreed that the steroid injections directly caused the syndrome.

       The district court granted summary judgment to Auto-Owners. Relying on the

factors in Continental Western Insurance Company v. Klug, 415 N.W.2d 876 (Minn.

1987), the district court determined that the syndrome did not arise out of the

maintenance or use of an automobile. The district court reasoned that the truck was not

actively connected to the injury and that the fall from the truck was not a substantial

factor in causing the syndrome. The district court further reasoned that Guillain-Barré


2
   The doctor further opined that the injections did not cause the syndrome, but this
factual issue was not raised by Auto-Owners in its summary-judgment motion.

                                             3
syndrome “caused by non-negligent medical treatment for a motor vehicle related injury

is not a foreseeable, natural, and reasonable consequence of motoring.” This appeal

followed.

                                     DECISION

       On appeal from a grant of summary judgment, this court asks two questions:

(1) whether any genuine issues of material fact exist and (2) whether the district court

erred in its application of the law. State by Cooper v. French, 460 N.W.2d 2, 4 (Minn.

1990). Here, the parties agree that no genuine issues of material fact are present.

       Dahler asserts that the district court erred because his automobile-related injury

necessitated the steroid injections, which in turn caused the syndrome. He argues that

this connection shows that treatment for the syndrome relates to his use of an automobile.

Auto-Owners counters that no causal relationship exists between the syndrome and the

motor vehicle. It further argues that, even if there is a causal relationship, the steroid

injections were an act of independent significance that broke the causal link. Finally,

Auto-Owners argues that because the vehicle was not the situs of the injury, no relief is

available. Because a causal link exists between the use of the motor vehicle and the

syndrome, which was not broken by the non-negligent medical treatment,3 we reverse

and remand.




3
  Neither party argues that the injections Dahler received were improper, negligent, or
medical malpractice.

                                             4
                 Arising Out of Maintenance or Use of an Automobile

      The no-fault act provides medical expense benefits for injuries “arising out of

maintenance or use of a motor vehicle.”         Minn. Stat. § 65B.46, subd. 1 (2012).

“Maintenance or use of a motor vehicle” includes “occupying, entering into, and

alighting from it.” Minn. Stat. § 65B.43, subd. 3 (2012). Whether an injury arises out of

the maintenance or use of a motor vehicle is a question of law that this court reviews de

novo. Dougherty v. State Farm Mut. Ins. Co., 699 N.W.2d 741, 743 (Minn. 2005).

      Determining whether an injury arises out of the use of a vehicle is a recurring legal

question that defies a simple test. Klug, 415 N.W.2d at 877. Each case turns on the

specific facts presented. Id. at 877–78. The Klug court set forth three general factors to

consider when addressing this issue: first, the court examines the extent of causation

between the automobile and the injury. Id. at 878. Second, the court considers whether

an act of independent significance occurred that broke the causal link between use of the

vehicle and the injuries inflicted. Id. If these two factors are met, the court then must

consider what type of use of the automobile was involved. Id.

      A.     Extent of Causation

      A causal connection between the injury and the use of a vehicle “is established if

the injury is a natural and reasonable incident or consequence of the vehicle’s use.”

Dougherty, 699 N.W.2d at 743 (quotation omitted). The causal connection must be

reasonably apparent. Associated Indep. Dealers, Inc. v. Mut. Serv. Ins. Cos., 304 Minn.

179, 182, 229 N.W.2d 516, 518 (1975).




                                            5
       In examining this factor, courts consider whether the vehicle was an “active

accessory” in causing the injury. Dougherty, 699 N.W.2d at 743 (quotation omitted).

This analysis does not require that the vehicle “actively cause the damages; rather, the

requirement is satisfied if the injury occurred because the vehicle’s use is actively

connected with the injury.” Illinois Farmers Ins. Co. v. Marvin, 707 N.W.2d 747, 752–

53 (Minn. App. 2006).

       “This causation standard requires something less than proximate cause in the tort

sense and something more than the vehicle being the mere situs of the injury.”

Dougherty, 699 N.W.2d at 743 (quotation omitted). The phrase “arising out of” is

broadly construed, id. at 744, and has been interpreted to mean “originating from,”

“having its origin in,” “growing out of,” or “flowing from,” Associated Indep. Dealers,

304 Minn. at 182, 229 N.W.2d at 518 (quotation omitted).

       The district court here noted, and the parties agree, that Dahler’s back injury arose

out of his use of a motor vehicle because he sustained it while entering his truck.

Medical expenses for treating that injury were properly covered under his no-fault policy.

The issue here is whether the requisite causal connection exists between Dahler

developing Guillain-Barré syndrome and his use of the motor vehicle. We conclude that

it does.

       But for the accident and resulting back injury, Dahler would not have sought

medical treatment that resulted in the syndrome. To be sure, “but for” causation has been

rejected in Minnesota in tort cases. See Harpster v. Hetherington, 512 N.W.2d 585, 586

(Minn. 1994). But the no-fault act “causation standard requires something less than


                                             6
proximate cause in the tort sense.” Dougherty, 699 N.W.2d at 743 (quotation omitted).

Moreover, the connection between the vehicle and the syndrome is also “reasonably

apparent.”   See Associated Indep. Dealers, 304 Minn. at 182, 229 N.W.2d at 518.

Dahler’s truck may not have actively caused the syndrome itself, but that is not required;

instead, the truck must be “actively connected with the injury.” Marvin, 707 N.W.2d at

752–53.

       Furthermore, courts construe the phrase “arising out of” broadly. Dougherty, 699

N.W.2d at 744.     This phrase can mean “originating from,” “having its origin in,”

“growing out of,” or “flowing from.” Associated Indep. Dealers, 304 Minn. at 182, 229

N.W.2d at 518 (quotation omitted). Because Dahler’s use of the vehicle caused his back

injury, and medical treatment for that injury caused him to develop the syndrome, the

syndrome grew out of and flowed from his use of an automobile. The required casual

connection between the use of an automobile and the injury in question is therefore met.

       B.     Act of Independent Significance

       The second Klug factor determines whether an act of independent significance

broke the causal link between use of the vehicle and the injury. Klug, 415 N.W.2d at

878. This factor is tied to the first factor: although a causal connection exists if “the

injury is a natural and reasonable incident or consequence of the vehicle’s use,”

Dougherty, 699 N.W.2d at 743 (quotation omitted), an independent intervening act

breaks the causal chain when it “is not a foreseeable risk[] associated with the use of the

covered automobile.” Lindsey v. Sturm, 436 N.W.2d 788, 790 (Minn. App. 1989).




                                            7
       Auto-Owners asserts that the steroid injections are acts of independent

significance that break the causal connection between Dahler’s back injury and the use of

his truck. After carefully reviewing the record, we disagree.

       We conclude that administration and receipt of the steroids shots that allegedly

caused Dahler’s syndrome cannot be viewed as “acts of independent significance” when

they were deemed appropriate medical steps in the treatment of Dahler’s back injury.

The Independent Medical Examiner specifically opined that the “steroid injections that

were given for [Dahler’s] back pain . . . were related to the back injury at that time . . . .”

The cost of these injections were paid for by the insurance company and they were

undertaken to remedy an injury that arose out of the use of an automobile.

       Since the possibility of receiving medical treatment is a well-known risk

associated with motoring, see Minn. Stat. § 65B.48, subd. 1 (2012) (requiring that all

motor vehicle owners maintain a no-fault insurance policy), the requisite connection

exists between Dahler’s use of the truck and the injuries that he sustained when receiving

treatment for his back injury. Cf. Edwards v. State Farm Mut. Auto. Ins. Co., 399

N.W.2d 95 (Minn. App. 1986) (recognizing connection between use of a vehicle and

injuries “when the injuries arise from a risk associated with motoring”), review denied

(Minn. Mar. 13, 1987).

       At trial, the parties will vigorously dispute whether Dahler’s Guillain-Barré

syndrome was in fact caused by the steroid injections and we express no opinion as to the

merits of Dahler’s claims. On the record before us, however, receiving these steroid




                                              8
shots is not an act of independent significance breaking the causal chain between

Dahler’s injury and the use of his truck.

       C.     Type of Use of the Automobile

       If the first two factors are met, a court must consider what type of use of the

automobile was involved. Klug, 415 N.W.2d at 878. Although not discussed by the

district court, we conclude in our de novo review of the undisputed facts that this factor is

met as well. The parties do not dispute that Dahler’s back injury occurred while entering

his truck, a use covered by the statute. See Minn. Stat. § 65B.43, subd. 3. Based on our

analysis above, we conclude that a nexus exists between the syndrome and the use of an

automobile for transportation purposes.

       Finally, we note that other states with similar no-fault laws have considered

analogous cases and have reached the same conclusions.           See Haff v. Hettich, 593

N.W.2d 383, 391–92 (N.D. 1999) (holding that no-fault benefits extend to those who

receive negligent medical treatment for injuries sustained in an automobile accident);

Varner v. Nationwide Mut. Ins. Co., 489 A.2d 918, 919–20 (Pa. Super. Ct. 1985) (finding

that an injury sustained as a result of negligent medical treatment of an automobile-

related injury is covered by no-fault insurance). Although these cases are not binding

upon us, their reasoning is persuasive.




                                             9
      In sum, because a causal connection exists between the Guillain-Barré syndrome

and Dahler’s use of a motor vehicle that was not severed by the medical treatment he

received, we reverse the grant of summary judgment in favor of Auto-Owners and

remand the case for further proceedings.

      Reversed and remanded.




                                           10
