FILED
                                                                  United States Court of Appeals
                                      PUBLISH                             Tenth Circuit

                     UNITED STATES COURT OF APPEALS                       July 13, 2012

                                                                      Elisabeth A. Shumaker
                                  TENTH CIRCUIT                           Clerk of Court


 FRANCES LEON HARVEY,

       Plaintiff - Appellant,

 v.                                                        No. 11-2164

 UNITED STATES OF AMERICA,

       Defendant - Appellee.


           APPEAL FROM THE UNITED STATES DISTRICT COURT
                  FOR THE DISTRICT OF NEW MEXICO
                    (D.C. NO. 2:08-CV-00107 MCA-CG)


Mickale Carter, Beaver Dam, Wisconsin (Burton Broxterman, Albuquerque, New
Mexico, with her on the briefs), appearing for Appellant.

John S. Koppel, Attorney, Appellate Staff, Civil Division (Tony West, Assistant Attorney
General; Kenneth J. Gonzales, United States Attorney; and Mark B. Stern, Attorney,
Appellate Staff, Civil Division, with him on the brief), Department of Justice,
Washington, DC, appearing for Appellee.


Before O’BRIEN, TYMKOVICH, and MATHESON, Circuit Judges.


MATHESON, Circuit Judge.
                                  I.    INTRODUCTION

       Frances Leon Harvey’s appeal stems from a Federal Tort Claims Act (“FTCA”)

lawsuit that Mr. Harvey brought against the United States government for complications

arising from an injury to his hand.

       Mr. Harvey claims that government employees injured him by (1) misdiagnosing

and delaying treatment of his hand fracture, and (2) performing negligent surgery on his

hand. He argues that the district court erred in holding the misdiagnosis/delay-in-

treatment claim (“misdiagnosis claim”) to be time-barred and in granting summary

judgment on the negligent surgery claim for failure to produce expert evidence. Also, as

a threshold matter, Mr. Harvey contends that the district court should have granted his

motion for default judgment.

       The district court agreed with Mr. Harvey that Navajo law is the substantive law

that should be applied to this case. But Mr. Harvey argues on appeal that the district

court failed to follow Navajo law in dismissing his negligent surgery claim.

       We hold that the district court properly denied Mr. Harvey’s motion for default

judgment. Although we disagree with the district court’s conclusion that the

misdiagnosis claim was time-barred, we conclude that Mr. Harvey’s failure to provide

expert evidence doomed both his misdiagnosis and surgical malpractice claims. Finally,

although the parties disagree about whether Arizona law or Navajo law applies, we need

not decide that issue because the outcome is the same under both.
                                            -2-
       Exercising jurisdiction under 28 U.S.C. § 1291, we affirm.

                                   II.    BACKGROUND

A. Factual Background

       Mr. Harvey is an enrolled member of the Navajo Tribe and resides on the Navajo

Reservation in New Mexico. Fort Defiance Indian Hospital (“FDIH”) is located on the

Navajo Reservation in Arizona. Indian Health Services is an agency of the United States

government and operates FDIH pursuant to a lease with the Navajo Nation.

       In early February 2004, Mr. Harvey fell on ice and hurt his right hand. On

February 6, 2004, he visited the walk-in clinic at FDIH, where his hand was x-rayed. The

radiology report on the x-ray notes a fracture of the base of the fifth metacarpal, but a

note from Mr. Harvey’s medical records states “X-rays all ok.” Aplt. Appx. at 126.

Health care providers at FDIH gave Mr. Harvey Motrin for his pain and advised him to

return in a month if his condition did not improve.

       On March 5, 2004, Mr. Harvey returned to FDIH. A note from that day again

states that “X-rays were ok.” 

Harvey was given more Motrin.

       On March 29, 2004, Mr. Harvey returned to FDIH and was x-rayed again. The

medical record from that visit notes a “[r]ight fifth metacarpal (digit) base fracture

2/6/04.” 

Harvey “was told he needs to see ortho ASAP.” 

Mr. Harvey visited FDIH’s orthopedic clinic. An orthopedic

surgeon determined that it was not possible to reduce the two-month-old fracture. The

medical record states “2 months old not possible to reduce now.” 

Harvey
                                             -3-
was provided with a splint and directed to “use [it] part time for comfort.” 

to return to the clinic in approximately two or three weeks.

       On April 20, 2004, Mr. Harvey returned to the orthopedic clinic. For the first

time, he was advised to undergo surgery. Mr. Harvey returned to the clinic on May 3,

2004, for a pre-operation appointment. The medical record reflects that on that day both

the surgery and “all adverse reactions” were discussed with Mr. Harvey. 

Harvey also signed a consent form, which states that “[c]ommon and important risks

associated with the proposed operation . . . include [i]nfection, [n]eural [v]ascular trauma,

[n]on-union, [and] [a]rthritis.” 

May 5, 2004, Mr. Harvey underwent

surgery on his hand.

       Mr. Harvey returned to the orthopedic clinic on May 10, 2004, for a follow-up

appointment. On May 13, 2004, he again returned because of hand pain. An x-ray

revealed no infection and that the hand was healing. Health care providers removed Mr.

Harvey’s stitches, recasted his hand, and instructed him to return to the clinic in four

weeks for cast removal and an x-ray.

       On June 10, 2004, Mr. Harvey came to the clinic and reported his hand was

swollen and turning yellow. He returned on June 16, 2004. The medical record from that

day states that Mr. Harvey’s hand was swelling but healing well. Mr. Harvey claims that

he was informed on June 16, 2004, that it would take a year for his hand to return to

normal.


                                             -4-
      On March 21, 2005, Mr. Harvey returned to the clinic and complained of pain. An

examination of his hand revealed ulnar nerve entrapment. The medical record states that

Mr. Harvey was instructed to wear a wrist support and to undergo physical/occupational

therapy. Mr. Harvey claims he was told that it would take “yet another year” for his hand

to return to normal. 

April of 2006, Mr. Harvey did not believe that his

hand was “right.” 

      On September 20, 2004, Mr. Harvey signed an Authorization for Use or

Disclosure of Health Information for records related to “Misdiagnos [sic] of R hand & L

knee” for the period of February 1, 2004, to August 31, 2004. 

purpose or

need for the disclosure indicated “Attorney-Roosenfelt.” 

2006, Mr. Harvey filed an administrative claim with the Department of

Health and Human Services. He described the basis of his claim as “[f]ailure to diagnose

broken bone in right hand. Surgery to repair fell below the standard of care. All took

place at [FDIH] . . . during February, March, April, and May of 2004.” 

the

box marked “Date and Day of Accident,” Mr. Harvey wrote “May 2004.” 

damages of $300,000.

      By letter dated July 10, 2006, counsel for Mr. Harvey advised that Mr. Harvey was

amending the amount of his claim from $300,000 to $2,016,120. Mr. Harvey believed

that the Navajo law concept of “nalyeeh” required this change. On July 16, 2007, Mr.


                                           -5-
Harvey’s counsel received a letter dated June 20, 2007, that denied the administrative

claim as untimely.

       On January 29, 2008, Mr. Harvey filed a complaint in the U.S. District Court for

the District of New Mexico. Mr. Harvey alleged that government health care providers

had initially misdiagnosed and failed to treat his hand injury and thereafter had

committed surgical malpractice. He brought the claim under the FTCA and sought

damages of $2,016,120 “pursuant to nalyeeh.” 

October 6, 2008, Mr. Harvey filed a motion for partial summary judgment.

The FTCA provides that, under certain conditions, the United States is liable for torts “in

accordance with the law of the place where the act or omission occurred.” 28 U.S.C.

§ 1346(b)(1). In his motion, Mr. Harvey asked the court to determine that his FTCA

action “is governed by the tort law of the Navajo Nation” because the triggering act or

omission occurred on the Navajo Reservation. Aplt. Appx. at 36. The Government

argued that “law of the place” in the FTCA refers to the “state” and that Arizona law

should apply. The district court granted Mr. Harvey’s motion on September 29, 2009.

The Government sought reconsideration of that decision, which was denied.

       On June 12, 2009, the Government filed a motion to dismiss Mr. Harvey’s claim

relating to the initial failure to diagnose and treat his hand injury, arguing that it was

barred by the two-year statute of limitation under 28 U.S.C. § 2401(b). The Government

argued that Mr. Harvey knew on March 29, 2004, that his hand was broken and had been

previously misdiagnosed but did not file his FTCA administrative claim until May 1,
                                              -6-
2006. Mr. Harvey opposed the motion, but the district court granted it in an order filed

March 9, 2010. The court held that the “failure-to-diagnose/failure-to-treat claims

accrued on April 20, 2004, when [Mr. Harvey] learned that more extensive care (i.e.,

surgery) was required to treat an injury that health care providers originally believed

could be taken care of with painkillers and an ice pack.” 

Harvey sought reconsideration, which the district court denied. The court

stated that “if anything, the circumstances support a determination that Mr. Harvey’s

claims of medical malpractice, to the extent those claims are based on FDIH providers’

failure to diagnose and treat his fractured hand, accrued on the earlier date of March 29,

2004,” but the court let the April 20, 2004, date stand because the Government had not

sought reconsideration on that point. 

September 21, 2010, the Government moved to dismiss Mr. Harvey’s

negligent surgery claim for lack of subject matter jurisdiction. The Government argued

that even if Navajo law is “the law of the place,” Mr. Harvey’s action should be

dismissed because he had not designated an expert witness who could establish the

Government’s negligent or otherwise wrongful conduct, as required under the FTCA.

Mr. Harvey contested the motion. On May 4, 2011, the district court issued an order

notifying the parties that it intended to convert the Government’s motion to dismiss for

lack of jurisdiction into a summary judgment motion.

       Meanwhile, on September 27, 2010, Mr. Harvey filed a motion for default

judgment, arguing that the Government had filed its answer one day late approximately
                                            -7-
30 months earlier. The Government opposed the motion, and the district court denied it

in an order filed April 22, 2011.

       On June 30, 2011, the district court granted summary judgment for the

Government. The court determined that Mr. Harvey, under the facts of his case, could

not proceed “on his claim of medical negligence” (negligent surgery) because he had

failed to proffer any expert medical evidence. 

district court explained

that it had entered a scheduling order on September 25, 2008, that required Mr. Harvey to

disclose “any expert witness to be used by Plaintiff at trial and to provide expert reports

. . . no later than December 23, 2008.” 

January 26, 2009, the court granted

a joint motion from the parties requesting, among other things, an extension of Mr.

Harvey’s expert disclosure deadline to May 18, 2009, and closing discovery generally on

July 15, 2009. Mr. Harvey twice moved for further extensions of this deadline, but those

requests were denied. He filed an unopposed motion to reschedule the trial, which the

district court granted—but that motion did not include another request for extension of

the expert discovery deadline. Mr. Harvey “never disclosed an expert witness in support

of his medical malpractice claim.” 

its order granting summary judgment for the Government, the district court

rejected Mr. Harvey’s argument that he had demanded nalyeeh under Navajo law and

therefore expert testimony was not required. The district court further rejected Mr.

Harvey’s claim that nalyeeh has “no requirement for a showing of negligence in the

Anglo sense of that legal concept.” 

court stated that “it strongly appears
                                             -8-
that expert medical testimony is necessary to establish the diagnosis and treatment of a

medical condition under Navajo law.” 

“to the extent that Navajo law is

silent,” the district court determined that the Navajo Nation Code “provides that the issue

may be decided according to comity with reference to the laws of the state in which the

matter in dispute may have arisen.” 

omitted).

       The district court then turned to Arizona law, stating that “‘Arizona courts have

long held that the standard of care normally must be established by expert medical

testimony.’” 

Seibel, 

, 492 (Ariz. 2009)). The

district court recognized there is an exception for matters of common knowledge but

found the exception did not apply in this case. The court further rejected Mr. Harvey’s

invocation of the res ipsa loquitur doctrine. The court found the doctrine inapplicable

because Mr. Harvey had “failed to demonstrate that his hand injury is a matter of

common knowledge among laymen or medical experts.” 

Harvey also argued that expert testimony was irrelevant because there was no

admissible evidence regarding what happened during the surgery. Rejecting that

argument, the district court explained that “it is the Plaintiff that bears the burden to

prove the essential elements of his medical malpractice claim by a preponderance of the

evidence.” 

the court held that “[i]n the absence of expert

testimony, there are no genuine issues of material fact on Plaintiff’s FTCA medical

malpractice claim and Defendant is entitled to judgment as a matter of law.” 

Harvey filed a notice of appeal on August 18, 2011.
                                              -9-
                                    III.   DISCUSSION

       On appeal, Mr. Harvey argues that the district court erred when it (1) denied his

motion for a default judgment; (2) held that his misdiagnosis claim was time-barred

because it accrued on April 20, 2004, the date he learned his broken hand would require

surgery;1 and (3) granted summary judgment to the Government regarding negligent

surgery due to Mr. Harvey’s failure to produce expert medical testimony. Mr. Harvey

also argues in his reply brief that, because the Government did not cross-appeal, we

should not address its argument that the district court erred in determining Navajo law is

the “law of the place” under the FTCA.

       We review a district court’s denial of a motion for default judgment for abuse of

discretion. Bixler v. Foster, 

, 761 (10th Cir. 2010). Whether a plaintiff has

“file[d] an FTCA claim within the two-year statute of limitations period is a matter we

review de novo.” Plaza Speedway Inc. v. United States, 

, 1266 (10th Cir.

2002). We also review a district court’s grant of summary judgment de novo. Kan. Penn

Gaming, LLC v. HV Props. of Kan., LLC, 

, 1284 (10th Cir. 2011).


       1
         Mr. Harvey prefers that his case not be broken into misdiagnosis and negligent
surgery claims but instead be united under the concept of nalyeeh, with the relevant
injury for accrual being when “bad feelings” developed. Nevertheless, he also argues
that the district court erred in its analysis of when a “failure to timely diagnose case”
should accrue. See Aplt. Br. 8-15. His complaint also alleges under nalyeeh that
government employees breached the appropriate standard of care in failing to promptly
diagnose and properly treat his condition and that “[t]he surgeon fell below the standard
of care in the timing, operative procedures, and the aftercare.” Aplt. Appx. at 17. Under
these circumstances, we find no error in the district court’s separation of the claims.

                                           -10-
       We affirm the district court’s denial of the default judgment motion and its

dismissal of Mr. Harvey’s claims. We conclude that the district court erred in holding the

misdiagnosis claim was time-barred, but we affirm dismissal of that claim and the

negligent surgery claim because expert evidence is needed for both and because Mr.

Harvey failed to present an expert. We do not consider whether the district court was

correct in its determination of the “law of the place” because the outcome is the same

whether Navajo or Arizona law applies.2

A. Default Judgment

       “[D]efault judgments are not favored by courts.” Katzson Bros., Inc. v. U.S.

E.P.A., 

, 1399 (10th Cir. 1988). Default judgments against the United

States are especially disfavored. See Fed. R. Civ. P. 55(d); Stewart v. Astrue, 

, 28 (1st Cir. 2009) (“The disfavor in which [default] judgments are held is especially

strong in situations where . . . the defendant is the government.”).

       Rule 55(a) of the Federal Rules of Civil Procedure provides that “[w]hen a party

against whom a judgment for affirmative relief is sought has failed to plead or otherwise

defend, and that failure is shown by affidavit or otherwise, the clerk must enter the

       2
        Whether Arizona law or Navajo law is the “law of the place,” such law would
include the Arizona or Navajo choice-of-law rules, respectively. See Richards v. United
States, 

, 10-14 (1962) (holding that “law of the place” in the FTCA refers to
the “whole law of the place” where the acts or omissions occurred, including choice-of-
law rules). Because we conclude that the outcome of this case would be the same under
Arizona or Navajo law, we need not analyze the choice of law rules of these jurisdictions.

                                            -11-
party’s default.” In this case, the Government filed its response to Mr. Harvey’s

complaint one day beyond the 60-day deadline provided in Rule 12(a)(2) of the Federal

Rules of Civil Procedure. Thus, Mr. Harvey argues that default judgment must be

entered pursuant to Rule 55(a).

       We hold that Mr. Harvey forfeited his right to seek a default judgment by waiting

two and a half years before filing his motion. See Kontrick v. Ryan, 

, 458

n.13 (2004) (“[F]orfeiture is the failure to make the timely assertion of a right.”

(quotations omitted)). Kontrick held that a party forfeited his right to assert the

untimeliness of an amended complaint by failing to raise the issue until after that

complaint was adjudicated on the merits. 

Mr. Harvey allowed over

two years of active litigation to pass before seeking a default judgment for a one-day

tardy answer, he forfeited his default judgment argument. Even if Mr. Harvey did not

forfeit this issue, the district court did not abuse its discretion in denying his motion.

       Rule 55(d) of the Federal Rules of Civil Procedure also blocks Mr. Harvey’s

argument. It provides that default judgments may be entered against the government

“only if the claimant establishes a claim or right to relief by evidence that satisfies the

court.” Because, as the district court concluded and as we conclude below, Mr. Harvey

did not provide satisfactory expert evidence to establish his claims, he is not entitled to

default judgment.

B. FTCA Liability

        We next review some basic requirements for FTCA liability. “[T]he United
                                             -12-
States may not be sued without its consent and . . . the existence of consent is a

prerequisite for jurisdiction.” United States v. Mitchell, 

, 212 (1983).

“[T]he United States can be sued only to the extent that it has waived its immunity.”

United States v. Orleans, 

, 814 (1976). “We should . . . have in mind that

the [FTCA] waives the immunity of the United States and . . . we should not take it upon

ourselves to extend the waiver beyond that which Congress intended. Neither, however,

should we assume the authority to narrow the waiver . . . .” Smith v. United States, 

, 203 (1993) (quotations omitted).

       The FTCA waives sovereign immunity and allows private parties to sue the United

States government under defined conditions. See United States v. Kubrick, 

,

117-18 (1979). As a threshold matter, timeliness “is one of the conditions of the

government’s waiver of sovereign immunity under the FTCA, and [a federal] court lacks

subject matter jurisdiction to proceed under the FTCA if a plaintiff fails to satisfy the

FTCA’s timing requirements set forth in § 2401(b).” Franklin Sav. Corp. v. United

States, 

, 1287 (10th Cir. 2004). Under 28 U.S.C. § 2401(b), “[a] tort claim

against the United States shall be forever barred unless it is presented in writing to the

appropriate Federal agency within two years after such claim accrues.”

       “[D]etermination of when a claim . . . accrues is a matter of federal, not state,

law.” Kynaston v. United States, 

, 508 (10th Cir. 1983). “Under the FTCA

a cause of action accrues at the time the plaintiff is injured, or, in a medical malpractice

action, when the plaintiff has discovered both his injury and its cause.” Id.; see also
                                             -13-


. The injury must arise from the negligence or wrongful act or

omission of a government employee, not solely from a condition that existed before the

medical treatment at issue. See 28 U.S.C. § 1346(b)(1).

       If an FTCA claim is timely, the conditions for waiver of sovereign immunity

further include that the alleged “injury” must have been “caused by the negligent or

wrongful act or omission of any employee of the Government . . . under circumstances

where the United States, if a private person, would be liable to the claimant in accordance

with the law of the place where the act or omission occurred.” 

mandates application of [the law of the place] to resolve questions of substantive

liability.” Cannon v. United States, 

, 1192 (10th Cir. 2003).

C. Timeliness of the Misdiagnosis Claim

       The Government acknowledges that Mr. Harvey’s negligent surgery claim was

timely but argues that his misdiagnosis claim is barred because he knew of his injury and

its cause more than two years before he filed his administrative claim on May 1, 2006.

The district court agreed, initially holding that “Mr. Harvey’s failure-to-diagnose/failure-

to-treat claims accrued on April 20, 2004, when he learned that more extensive care (i.e.,

surgery) was required to treat an injury that health care providers originally believed

could be taken care of with painkillers and an ice pack.” Aplt. Appx. at 251.

       Mr. Harvey filed a motion for reconsideration. He argued that he could not have

known whether the delay in treatment caused the need for surgery. He further argued that

a reasonable person could conclude that the fracture had always required surgery.
                                            -14-
          The district court’s reasoning changed when it responded to Mr. Harvey’s motion

for reconsideration. It then concluded that “it would have been March 29, 2004 that Mr.

Harvey would or should have discovered the claimed injury, i.e., that a failure to

diagnose a fracture caused improper healing of his hand.” 

this change

in reasoning and change in dates, the district court stated that

                 because the [G]overnment has not asked the Court to
                 reconsider its earlier accrual-date finding, and it would be
                 unfair to Mr. Harvey for the Court sua sponte at this point to
                 deem March 29, 2004 the date of accrual of his first set of
                 medical malpractice claims, the Court will stand by its earlier
                 conclusion that Mr. Harvey’s claims, to the extent they arose
                 from a failure to diagnose and operate, accrued on April 20,
                 2004.

either analysis, the district court erred in concluding that Mr. Harvey’s

misdiagnosis claim was time-barred. Both Mr. Harvey and the district court relied on

reasoning from the Ninth Circuit regarding the factors that must be considered for accrual

when a plaintiff alleges, as Mr. Harvey does here, that a misdiagnosis and consequent

lack of proper treatment produced a more serious condition than the original illness or

injury.

                 When a physician’s failure to diagnose, treat, or warn a
                 patient results in the development of a more serious medical
                 problem than that which previously existed, identification of
                 both the injury and its cause may be more difficult for a
                 patient than if affirmative conduct by a doctor inflicts a new
                 injury. Where a claim of medical malpractice is based on the
                 failure to diagnose or treat a pre-existing condition, the injury
                 is not the mere undetected existence of the medical problem
                                               -15-
              at the time the physician failed to diagnose or treat the patient
              or the mere continuance of that same undiagnosed problem in
              substantially the same state. Rather, the injury is the
              development of the problem into a more serious condition
              which poses greater danger to the patient or which requires
              more extensive treatment. In this type of case, it is only when
              the patient becomes aware or through the exercise of
              reasonable diligence should have become aware of the
              development of a pre-existing problem into a more serious
              condition that his cause of action can be said to have accrued
              for purposes of section 2401(b).

Augustine v. United States, 

, 1078 (9th Cir. 1983) (emphases added); see

also Hughes v. United States, 

, 276-77 (3rd Cir. 2001); Green v. United

States, 

, 108-09 (7th Cir. 1985). We agree with this approach but disagree

with the district court’s application of it to Mr. Harvey’s misdiagnosis claim.

       The injury alleged in Mr. Harvey’s complaint was “that his hand would never

function properly and that it would always hurt” due to medical malpractice. Aplt. Appx.

at 15. He alleged his hand would have healed with proper care—thus, he alleged that

doctors at FDIH caused a more serious condition to develop in his hand.

       We apply the Augustine standard. Before Mr. Harvey’s misdiagnosis claim could

accrue, he must have been aware—or through the exercise of reasonable diligence should

have been aware—that the lack of proper treatment had caused his broken hand to

develop into a more serious condition. See 

. On March 29,

2004, Mr. Harvey discovered that he had a broken hand, but there is no evidence to

suggest that this discovery showed him that the lack of proper treatment had further

damaged his hand beyond the injury caused by his fall. On April 20, 2004, he discovered
                                            -16-
he needed surgery. But, again, nothing in the record suggests that this should have

informed him that he had developed a more serious condition since the fall. A reasonable

person in his position could not have known whether surgery would have been necessary

even if there had been no misdiagnosis.3

       This reasoning is consistent with Tenth Circuit precedent. In misdiagnosis cases,

we have consistently held that the relevant injury for accrual is the injury that is caused

by the misdiagnosis and lack of treatment, not the pre-existing injury that brought the

patient to the doctor’s door. See, e.g., Arvayo v. United States, 

, 1419-22

(10th Cir. 1985); Gustavson v. United States, 

, 1035 (10th Cir. 1981).

       For example, in Gustavson, when Mr. Gustavson was a child, he visited military

doctors regarding a bedwetting 

. The doctors misdiagnosed

anxiety as the cause of the problem. 

and a resulting

infection had caused the problem. 

informed Mr.

Gustavson of the mistake. 

told him that corrective surgery could

have been performed years earlier and that the untreated and long-continued reflux had

caused serious damage to his kidneys. 

held that Mr. Gustavson’s claim accrued under 28 U.S.C. § 2401(b) when he

learned from the civilian doctors that his kidneys were damaged by the misdiagnosis and

       3
        The medical record from Mr. Harvey’s visit to FDIH on March 30, 2004, notes
that the break is “2 months old not possible to reduce now.” Aplt. Appx. at 133. But
nothing in the record indicates that Mr. Harvey was told this or that it would have been
possible to reduce the fracture if it had been treated earlier.

                                            -17-
consequent failure to correct the ureter disorder at an earlier stage. 

Gustavson had two years from that point to file a claim, but he failed to do so. 

rejected Mr. Gustavson’s argument that there was not accrual until he later

realized that the kidney damage was irreversible. 

“a claimant is

aware of the injury once he or she has been apprised of the general nature of the injury.

Lack of knowledge of the injury’s permanence, extent, and ramifications does not toll the

statute.” 

Gustavson was apprised of his kidney damage that became

worse from lack of treatment, his claim accrued and the FTCA two-year limitation period

began to run. See 

case, the relevant injury is the injury caused by misdiagnosis and

lack of treatment, not the original broken hand.4 The district court improperly equated

the necessity of surgery and the knowledge that he had not received proper treatment with

knowledge of the development of a more serious condition.

       Mr. Harvey knew his hand was broken beginning on March 29, 2004, but that was

not knowledge that his hand had developed a more serious condition beyond the initial

fracture due to the lack of prompt treatment. On April 20, 2004, he was told he would

need surgery. But, again, that did not give him knowledge that surgery would have been


       4
        Mr. Harvey mistakenly argues that his misdiagnosis claim could accrue only
when he allegedly realized his hand would never fully heal. He did not have to know his
injury was permanent. But he did have to know that his hand had developed a more
serious condition because of the lack of proper treatment, or a court must hold that he
reasonably should have known it.

                                            -18-
unnecessary before the delay in proper treatment. Nothing in the record shows that Mr.

Harvey knew or reasonably should have known before May 2004 that his hand had

developed a more serious condition due to the misdiagnosis and consequent delay in

treatment.

       We therefore hold that Mr. Harvey’s misdiagnosis claim, originally filed as an

administrative claim on May 1, 2006, is not time-barred under 28 U.S.C. § 2401(b).

However, as explained below, we affirm the district court’s dismissal of that claim on the

same ground that the district court relied upon for dismissal of the negligent surgery

claim.5

D. Expert Evidence Required on Mr. Harvey’s Claims

       We turn to whether Mr. Harvey’s claims can survive summary judgment without


       5
        “We have discretion to affirm on any ground adequately supported by the
record.” Elkins v. Comfort, 

, 1162 (10th Cir. 2004). “In exercising that
discretion we consider whether the ground was fully briefed and argued here and below,
whether the parties have had a fair opportunity to develop the factual record, and
whether, in light of . . . [the] uncontested facts, our decision would involve only questions
of law.” 

omitted); see also United States v. Damato,

, 844 (10th Cir. 2012) (concluding it was appropriate to address an
alternative ground that had not been argued by the parties because “the second and third
Elkins factors . . . weigh[ed] in favor of considering the alternative ground”).
       The alternative ground on which we affirm the dismissal of Mr. Harvey’s
misdiagnosis claim—that expert evidence is required here to prove medical
malpractice—was fully briefed on appeal and in the district court as the ground on which
the negligent surgery claim failed. Additionally, in light of the uncontested facts, our
consideration of this alternative ground involves only a question of law. Finally, we note
that Mr. Harvey had a fair opportunity to develop the factual record concerning his
misdiagnosis claim because the deadlines for presenting an expert witness and
conducting discovery expired well before the district court dismissed his claim.

                                            -19-
expert evidence. As noted above, “the FTCA mandates application of [the law of the

place] to resolve questions of substantive liability.” 

. In most

FTCA cases, “law of the place” means the law of the state where the act or omission

occurred. See, e.g., FDIC v. Meyer, 

, 478 (1994) (“[W]e have consistently

held that § 1346(b)’s reference to the ‘law of the place’ means law of the State—the

source of substantive liability under the FTCA.”). Because of the “law of the place”

language, federal courts generally look to state law to determine whether an FTCA

malpractice case requires expert evidence. See Gipson v. United States, 

,

451-52 (7th Cir. 2011); Cleveland ex rel. Cleveland v. United States, 

, 403

(5th Cir. 2006).

       All pertinent events in this case occurred in Arizona on the Navajo Reservation,

and the district court decided that Navajo law was the “law of the place.” But in ruling

that Mr. Harvey’s surgical malpractice claim should be dismissed, the court relied on

Arizona law that calls for the presentation of expert testimony to establish a medical

malpractice claim. The court did so because, in its view, Navajo law likely requires

expert evidence for such a claim and, insofar as Navajo law is silent on the issue, Navajo

courts would look to Arizona law as a matter of comity.

       Not surprisingly, Mr. Harvey disagrees with the district court’s analysis and

argues that the Navajo law of nalyeeh governs his claim and that nalyeeh does not require

him to prove “intent, causation, fault, or negligence.” Aplt. Reply Br. at 11. He also

contends that the Government cannot challenge the district court’s “law of the place”
                                           -20-
ruling because it did not cross-appeal.

       We need not decide whether the phrase “law of the place” in the FTCA requires

application of Navajo law or Arizona law because the outcome is the same under both—

Mr. Harvey’s failure to provide expert evidence on the issues of injury, causation,

negligence, or wrongful act or omission rendered summary judgment appropriate on both

his misdiagnosis and surgical malpractice claims under Navajo or Arizona law.

       Further, although we understand Navajo Nation Supreme Court precedent to

require expert proof in cases like this one, even if Mr. Harvey were correct that his

nalyeeh claim does not require proof of causation, negligence, or fault, the FTCA

requires proof of those elements, and such proof calls for expert evidence here.

       Accordingly, we first address Mr. Harvey’s claims under Arizona law and then

consider Navajo law. We conclude in both instances that summary judgment was

appropriate on Mr. Harvey’s substantive claims.

   1. Arizona Law as Law of the Place Under the FTCA

       Although Mr. Harvey argues that Navajo law is the law of the place and thus

should control liability under the FTCA, he argues, in the alternative, that the district

court was incorrect in dismissing his negligent surgery claim based upon the requirement

under Arizona law that a plaintiff must present expert evidence to establish liability in a




                                             -21-
medical malpractice case.6

       Both the misdiagnosis and negligent surgery claims are allegations of medical

malpractice. The Arizona Supreme Court has explained that “[i]n medical malpractice

actions, as in all negligence actions, the plaintiff must prove the existence of a duty, a

breach of that duty, causation, and damages.” Seisinger v. Siebel, 

, 492

(Ariz. 2009) (en banc). “The yardstick by which a physician’s compliance with his duty

is measured is commonly referred to as ‘the standard of care.’” 

courts have long held that the standard of care normally must be established by

expert medical testimony.” 

also long held that expert testimony

on the standard of care can be presented only by a physician.” 

held

that this latter requirement, as codified in Ariz. Rev. Stat. § 12-2604, is substantive in

nature. 

law further provides that “[o]rdinarily, a plaintiff in a medical malpractice

lawsuit must prove the causal connection between an act or omission and the ultimate

injury through expert medical testimony, unless the connection is readily apparent to the

trier of fact.” Benkendorf v. Advanced Cardiac Specialists Chartered, 

, 706

(Ariz. Ct. App. 2012) (quotations omitted).

       Mr. Harvey did not produce a medical expert. He argues that under the facts of


       6
       Technically the district court did apply Navajo law and looked to Arizona law
under principles of comity, but Mr. Harvey argues Navajo law would not consider
Arizona law in the context of this case.

                                             -22-
this case Arizona law does not require an expert because (1) the surgical medical record

is so unreliable that expert analysis of it would be useless, and (2) res ipsa loquitur

applies.7

       a. Expert Testimony Required

       Arizona law regarding evidence in medical malpractice claims would require

expert testimony to establish both Mr. Harvey’s misdiagnosis and his negligent surgery

claims.

       First, as to the misdiagnosis claim, although it may be readily apparent that the

misdiagnosis was either negligent or wrongful, it is not readily apparent that the

misdiagnosis and lack of treatment caused injury to Mr. Harvey’s hand beyond the initial

fall. The radiology report notes a fracture from the date Mr. Harvey first arrived at

FDIH. Mr. Harvey was not informed of or treated for a broken hand for an extended

period. A reasonable juror could determine that this misdiagnosis involved negligent or


       7
           Res ipsa loquitur is a doctrine that

                 allows a trier of fact to draw an inference of negligence when
                 (1) the injury is “of a kind that ordinarily does not occur in
                 the absence of negligence,” (2) the injury is “caused by an
                 agency or instrumentality subject to the control of the
                 defendant,” and (3) the claimant is not “in a position to show
                 the particular circumstances that caused the offending agency
                 or instrumentality to operate to her injury.” Lowrey v.
                 Montgomery Kone, Inc., 

, ¶ 7, 

, 623
                 (App. 2002).

Sanchez v. Old Pueblo Anesthesia, 

, 1289 (Ariz. Ct. App. 2008).

                                                  -23-
wrongful conduct without the aid of expert testimony. See David H. Kaye, The New

Wigmore: A Treatise on Evidence, Expert Evidence § 2.5 (“[I]n certain rare

circumstances, expert testimony is not necessary in a medical negligence case because

the alleged acts of negligence clearly lie within the range of the jury’s common

knowledge and experience.” (quotations omitted)).

         But whether that misdiagnosis and the delay in proper treatment caused some

further injury to the hand—beyond the injury caused by the initial fall on the ice—is not

readily apparent to a person without professional medical training. Mr. Harvey needs an

expert to prove that the misdiagnosis and failure to treat produced a more serious injury

to his hand.

         Second, as to the surgical malpractice claim, Mr. Harvey argues that the medical

record regarding his surgery is so inadequate that it offers no assistance in evaluating his

claim. He contends that, without the benefit of a reliable record, a layperson “is in as

good a position as a medical expert to determine what occurred during the surgery,” and

“Fed. R. Evid. 702 prohibits the use of an expert witness in this circumstance.” Aplt. Br.

at 26.

         Even accepting Mr. Harvey’s allegation that the record of the surgery is unreliable,

his arguments fail. An expert could and should analyze other evidence of the surgery and

other treatment provided—including x-rays and medical records from Mr. Harvey’s

multiple visits to FDIH both before and after his surgery, and the testimony of treating


                                             -24-
physicians and other health care providers.8

       It is not readily apparent to a lay person whether the surgery performed on Mr.

Harvey’s hand was negligent or wrongful or that it caused injury. Mr. Harvey claims he

was told his hand would return to normal within a year. But such a statement does not

establish that the doctors caused an injury through some negligent or wrongful conduct or

omission.

       As to both claims, even competent medical care is not always fully successful at

fixing injuries. Considering the facts of this case, a lay jury cannot determine whether

Mr. Harvey’s hand was damaged by inadequate medical care without the assistance of

qualified expert opinion. Reaching such an opinion demands professional analysis of the

severity of his initial injury, the probability of recovery with proper treatment, the

medical effects of delaying proper treatment, the propriety of surgery, the proper standard

of care for the surgery, and whether that standard was met. The misdiagnosis claim

would require expert testimony to show cause and injury, and the negligent surgery claim

would require expert testimony to establish cause, injury, and negligence or other

wrongful conduct or omission.

       8
        Contrary to Mr. Harvey’s assertions, Rule 702 of the Federal Rules of Evidence
would allow the testimony of a qualified expert if it would “assist the trier of fact to
understand the evidence or to determine a fact in issue” and is “based upon sufficient
facts or data, . . . [and] is the product of reliable principles and methods” that have been
applied “reliably to the facts of the case.” In addition, Rule 703 provides that “[t]he facts
or data in the particular case upon which an expert bases an opinion or inference may be
those perceived by or made known to the expert at or before the hearing.”


                                             -25-
       Without a medical expert concluding there were injurious consequences from the

misdiagnosis, delay of treatment, or some other negligent or wrongful act or omission

during Mr. Harvey’s surgery or other treatment, no jury or court could reliably determine

if government employees caused injury to Mr. Harvey’s hand. Thus, under the facts of

this case, Mr. Harvey was required to produce an expert under Arizona law. See

.

       b. Res Ipsa Loquitur Not Applicable

       Mr. Harvey’s res ipsa loquitur argument under Arizona law fails for similar

reasons. He asserts that he should benefit from a rebuttable presumption that his hand

was injured by the government doctors’ negligence because “[t]he surgery was under the

complete and exclusive control of the Defendant,” and “[t]he ordinary outcome of this

surgery is complete recovery.” Aplt. Br. at 29.

       But Mr. Harvey cannot show without an expert that complete recovery would be

the normal outcome of his surgery had the proper standard of care been met. To do so, he

would need a medical expert to testify as to the severity of his pre-existing injury, the

potential for recovery, the proper standard of care in his surgery, and the likelihood that it

was met. The district court explained that “‘[r]es ipsa loquitur is applicable only when it

is a matter of common knowledge among laymen or medical experts, or both, that the

injury would not ordinarily have occurred if due care had been exercised.’” Aplt. Appx.

at 389 (alteration omitted) (quoting Sanchez v. Old Pueblo Anesthesia, 

,

1289 (Ariz. Ct. App. 2008)). Mr. Harvey’s assertion that he was told his hand would get
                                             -26-
better within a year is insufficient to make that showing.

       Furthermore, under Arizona law, res ipsa loquitur is used to establish negligence,

not injury or cause. See 

(explaining that res ipsa loquitur

“allows a trier of fact to draw an inference of negligence” under certain conditions). One

of the elements Mr. Harvey must show to benefit from that doctrine is that “the injury is

caused by an agency or instrumentality subject to the control of the defendant.” 

Mr. Harvey would need expert testimony to establish injury

and cause before he could benefit from this doctrine. Res ipsa loquitur cannot

circumvent the need to show injury and cause, see 

requirement to

present expert testimony under the facts of this case.

       c. Remand to Produce Experts Not Warranted

       Mr. Harvey argues that if we hold expert testimony is necessary, we should

remand and allow him to provide such testimony. But Mr. Harvey was already given a

chance to provide experts before the district court. The district court ordered Mr. Harvey

to identify any expert witness by December 23, 2008. The deadline was later extended to

May 18, 2009, long before the dismissal of both his misdiagnosis and negligent surgery

claims.9 “Although [Mr. Harvey] twice moved for an extension of this discovery

deadline, the requested extensions were denied.” Aplt. Appx. at 377. Because Mr.

       9
       Mr. Harvey’s misdiagnosis claim was dismissed as time-barred on March 9,
2010. Summary judgment against the rest of his substantive claims was granted on June
30, 2011.


                                            -27-
Harvey did not comply with the district court’s order, which extended the deadline by

nearly five months, we do not agree with Mr. Harvey’s argument that equitable principles

demand remand.

       d. Conclusion Under Arizona Law

       For the foregoing reasons, the district court did not err when it held under Arizona

law that Mr. Harvey’s negligent surgery claim required medical expert testimony. Mr.

Harvey’s misdiagnosis claim would also require expert testimony to show cause and

injury beyond the initial injury to his hand. If the law of the place were Arizona law, it

would therefore be proper for the district court to dismiss those claims on summary

judgment because Mr. Harvey failed to provide experts for trial.

   2. Navajo Law as the Law of the Place Under the FTCA

       If, as Mr. Harvey argues, Navajo law applies, the result is the same.

       a. Nalyeeh as Applied in Navajo Courts

       Mr. Harvey asserts his claim under nalyeeh. The Navajo Nation Supreme Court

has explained that “[g]enerally, nalyeeh means compensation for an injury. However, it

has a deeper meaning of a demand to make right for an injury and an invitation to

negotiate what it will take so that an injured party will have no hard feelings.” Benally v.

Big A Well Service, Co., No. SC-CV-27-99, ¶ 22 (Nav. Nat. Sup. Ct. Aug. 28, 2000)

(quotations omitted). Nalyeeh is thus not a particular cause of action with specific

elements to prove—it is more akin to “a form of compensation or reparation” that may be

demanded in the context of any number of claims (including negligence or wrongful
                                            -28-
conduct or omission) when “a Navajo was injured by the act of another.” Largo v. Eaton

Corp., No. SC-CV-09-99, ¶ 25 (Nav. Nat. Sup. Ct. Apr. 11, 2001). It “includes the

responsibility to respectfully talk out disputes” and is used “to assess the adequacy of

damages in tort claims.” Allstate Indemnity Co. v. Blackgoat, No. SC-CV-15-01, ¶ 27

(Nav. Nat. Sup. Ct. Jan. 12, 2005). It is a “process for restoring relationships between the

injured party and the tortfeasors.” Joe v. Black, No. SC-CV-62-06, ¶ 18 (Nav. Nat. Sup.

Ct. Nov. 29, 2007).

       Mr. Harvey argues that nalyeeh “is not concerned with intent, causation, fault, or

negligence” and therefore requires no expert testimony.10 Aplt. Reply Br. at 11

(quotations omitted). He argues that the relevant injury we should consider is the “bad

feelings” that arose when he realized his hand would not get better.

       We understand from Navajo Nation Supreme Court precedent that a Navajo court

would consider issues of negligence, cause, and fault in a case like the one before us. See

Joe, No. SC-CV-62-06 at ¶¶ 25-26 (explaining that negligence is “part and parcel of

nalyeeh” and that “the Navajo Nation Code mandates the application of negligence

principles”); Jensen v. Giant Indus., Ariz., No. SC-CV-51-99 (Nav. Nat. Sup. Ct. Jan. 22,

2002) (“As a general rule, the tort of negligence has four components—a duty to the

person injured, a breach of that duty, causation, and resulting damages.”).


       10
         This statement is at odds with Mr. Harvey’s complaint, which asserts his claim
under nalyeeh and argues that government doctors breached the proper standard of care
in multiple respects and caused damage to his hand.

                                            -29-
       Moreover, even Mr. Harvey does not argue that nalyeeh requires no showing of

injury. Indeed, the Navajo law expert quoted by Mr. Harvey, former Chief Justice Robert

Yazzie, stated that nalyeeh “is a demand that the victim be made whole for an injury.”

Aplt. Reply Br. at 11 (quotations omitted). It is the injury that produces the bad feelings

for which Mr. Harvey seeks compensation under nalyeeh. See 

without testimony from a medical specialist, a layperson

cannot reliably determine if Mr. Harvey is suffering from anything more than the

unavoidable effects of his initial fall on the ice. The Navajo Nation Supreme Court has

stated that nalyeeh may be demanded when “a Navajo was injured by the act of another.”

Benally, No. SC-CV-27-99 at ¶ 22. Without expert testimony, Mr. Harvey cannot

reliably show injury or whether the injury was due to “the act of another.” See 

Supreme Court has recognized the need for expert testimony

where a layperson is not qualified to provide a reliable analysis. See Baldwin v. Chinle

Family Court, No. SC-CV-37-08, 5 (Nav. Nat. Sup. Ct. Oct. 30, 2008). The Baldwin

Court reversed the findings of a family court. The Supreme Court explained that “[n]o

evidence was produced before the Court that the mother’s health care providers had been

consulted as to inform the Court of Ms. Baldwin’s present ability to care for the child or

revealed any current condition which suggested an on-going inability of the mother to

care for her child.” Baldwin, No. SC-CV-37-08 at 3 (emphasis added). The Court

further explained that “diagnosis of an individual requires professional expertise.” 

added).
                                            -30-
       In Mr. Harvey’s case, the district court surmised that “[p]ursuant to Baldwin, it

strongly appears that expert medical testimony is necessary to establish the diagnosis and

treatment of a medical condition under Navajo law.” Aplt. Appx. at 385. We agree with

the district court. Furthermore, when medical analysis would be beyond the scope of

common knowledge, Baldwin indicates that medical experts are necessary under Navajo

law.

       Because this case requires medical analysis beyond the scope of common

knowledge to show “injury by the act of another,” see Benally, No. SC-CV-27-99 at ¶ 22,

Navajo law indicates that Mr. Harvey’s claim would require expert testimony.

       b. The FTCA and Mr. Harvey’s View of Nalyeeh

       Even if nalyeeh does not require proof of cause, fault, or negligence, as Mr.

Harvey contends, he cannot succeed on an FTCA claim without showing that a

government employee caused his injury through some “negligent or wrongful act or

omission.” 28 U.S.C. § 1346(b)(1). Thus, if Mr. Harvey cannot show that he received

injury to his hand through the negligent or wrongful act or omission of a government

health care provider, the FTCA itself would bar recovery, notwithstanding the applicable

“law of the place.” See Laird v. Nelms, 

, 799 (1972) (citation omitted)

(quotations omitted) (“Regardless of state law characterization, the [FTCA] itself

precludes the imposition of liability if there has been no negligence or other form of

misfeasance or nonfeasance on the part of the Government.” (emphasis added)). Because

proving injury and cause would require scientific or specialized medical knowledge that
                                            -31-
would be helpful to a lay jury, Rules 701 and 702 of the Federal Rules of Evidence would

prohibit a layperson from offering such evidence but would allow a properly qualified

expert to do so.

       Thus, even if we were to accept Mr. Harvey’s arguments regarding Navajo law

requirements, he still could not succeed on his substantive claims without providing a

medical expert.

                                   IV.    CONCLUSION

       We affirm the district court’s denial of Mr. Harvey’s default judgment motion

because Mr. Harvey waited over two years to file the motion, and he cannot establish his

claims against the Government with satisfactory evidence. We conclude that the district

court erred when it held that Mr. Harvey’s misdiagnosis claim was time-barred. We

further conclude that regardless of whether the law of the place is Arizona or Navajo law,

Mr. Harvey cannot prove his claims without expert testimony because such testimony is

necessary to show that government employees caused additional injury to Mr. Harvey’s

hand after his fall through negligence or wrongful act or omission. The district court

gave Mr. Harvey ample opportunity to provide medical experts, and Mr. Harvey failed to

do so. We affirm dismissal of those claims and therefore affirm the district court’s

judgment.




                                           -32-