NOT DESIGNATED FOR PUBLICATION
HUGHES, J.
This is an appeal of an award in favor of the plaintiff, following a jury trial in a medical malpractice suit. For the reasons that follow, we affirm.
On July 23, 2003 Shirley Cooper sought treatment at Lallie Kemp Hospital, complaining of a persistent headache. While there, she was found to be experiencing neurological symptoms, and since Lallie Kemp did not have a neurologist on staff, it was determined that Ms. Cooper should be transferred to a facility with a neurologist on staff. She was later transferred to North Oaks Medical Center, where she was diagnosed as having suffered multiple strokes, and anticoagulants were administered. Ms. Cooper never made a complete recovery and was confined to nursing homes for the next six years, until her death in May of 2009.
On November 22, 2006 Ms. Cooper brought the instant suit against the State of Louisiana, Department of Health and Hospitals, Lallie Kemp Hospital ("Lallie Kemp"),1 and Louisiana State University Health Sciences Center, Health Care Service Division (hereinafter referred to collectively as the "State"), contending that Lallie Kemp failed to "properly and responsibly treat her during a 10 hour stay at the emergency room where she had a stroke on July 23, 2003." Ms. Cooper further alleged that on July 23, 2003, the triage nurse "signed off at 10:55, noting complaints of a headache for 1 week and history of recent left-sided stroke, which had also been diagnosed and treated at that same emergency room," and that her blood pressure was elevated at 188/99. Ms. Cooper alleged that she was left for several hours waiting to see a doctor, and during this time she developed right-sided weakness, slurred speech, and right facial droop. Ms. Cooper alleged that she was seen by a doctor at 12:55, who noted the old left-sided stroke symptoms and the new right-sided symptoms. Ms. Cooper also alleged that the doctor reviewed her prior CT scan, showing that her prior stroke was occlusive (embolic) and not hemorrhagic. Ms. Cooper further alleged that when she was treated several months earlier at Lallie Kemp for her left-sided stroke, Lallie Kemp administered aspirin to her, performed cardiac monitoring, acted to lower her blood pressure, treated her potassium deficiency, and admitted her to the hospital. Her outcome for the prior stroke was "vastly better," and she returned to a normal life. Ms. Cooper contended that on July 23, 2003, even though she was in the ER during daytime hours and on a weekday, Lallie Kemp: failed to order blood work, glucose monitoring (though Lallie Kemp had diagnosed her with diabetes on May 29, 2003), or cardiac monitoring; failed to provide her with aspirin or any other anticoagulant treatment; failed to provide her with timely and sufficient oxygen support or monitor her blood oxygen levels; failed to obtain a neurology consult until nine hours after she arrived in the ER and eight hours after the ER doctor noted signs of stroke; and made no attempt to arrange a transfer to another hospital until more than six hours after the ER doctor recorded signs of stroke. Ms. Cooper alleged that Lallie Kemp was negligent: in adopting a "do nothing" approach to treating her stroke; in downplaying the significance of her May 2003 left-sided stroke; in failing to timely obtain a neurology consult; in failing to timely arrange transport to another hospital; in failing to timely order blood work or institute glucose, oxygen saturation, and cardiac monitoring; in failing to timely order the administration of sufficient oxygen; in failing to take measures to lower her elevated blood pressure; in failing to provide her with aspirin or other anticoagulant medication; and in failing to render other palliative care.
Subsequent to Ms. Cooper's death on May 20, 2009, a supplemental and amending petition was filed on June 10, 2009, substituting as party plaintiffs her sons, Oscar J. Cooper, Jr., and Austin T. Cooper, who further alleged the wrongful death of their mother, which they asserted arose from the "same transactions and occurrences at Lallie Kemp on July 23, 2003 that were alleged in the original petition." Pauline Holden was later substituted as plaintiff in this suit, having been named the legal representative of Oscar Cooper and Austin Cooper, who were both interdicted as to their financial and legal affairs only, by a September 25, 2009 order of the 21st Judicial District Court.
The State answered the suit, denying liability and affirmatively asserting: the applicability of the statutory limitation of recovery set forth in LSA-R.S. 40:1299.39(F);2 the contributory negligence of Ms. Cooper, in failing to mitigate her damages; and that the alleged injury, condition, complications, and/or damage to Ms. Cooper was caused by one or more of the plaintiffs, another healthcare provider, or another entity, person, or party, named or not named, over whom the State had no control and for whom the State was not responsible or liable.
The jury's answers to the jury interrogatories, during the November 2010 jury trial, were, as recited in the trial court judgment, as follows, in pertinent part:
1. Did Lallie Kemp Medical Center through their medical staff fail to meet the required standard of care?
Yes
* * *
2. Did Shirley Cooper suffer damage caused from the failure to meet the standard of care by Lallie Kemp Medical Center?
Yes
* * *
3. What amount of damages do you find that Shirley Cooper suffered as a result of a failure to meet the standard of care by Lallie Kemp Medical Center?
Medical Expenses: $1,032,599.50
Pain and Suffering $750,000
Disability $180,000
Loss of Enjoyment of Life $1,000,000
Mental Distress $1,250,000
4. Was the failure to meet the standard of care by Lallie Kemp Medical Center a cause of the death of Shirley Cooper?
Yes
* * *
5. Was Shirley Cooper at fault in her death?
Yes
* * *
6. Did Shirley Cooper's fault legally cause or contribute to her death by consuming food?
Yes
* * *
7. What percentages of fault do you assign Shirley Cooper and Lallie Kemp Medical Center for the death of Ms. Cooper? The total must add up to 100%.
Shirley Cooper 25% Lallie Kemp 75%
* * *
8. What amount, if any, do you feel will fully compensate Oscar Cooper, Jr., Ms. Shirley Cooper's son, for the loss of love and affection, companionship and guidance as a result of her death caused by the failure to meet the standard of care in this case?
$150,000
9. What amount, if any, do you feel will fully compensate Austin "Tyrone" Cooper, Ms. Shirley Cooper's son, for the loss of love and affection, companionship and guidance as a result of her death caused by the failure to meet the standard of care in this case?
$150,000
Based on the jury's verdict, the trial court signed a judgment on July 27, 2011 against the State and in favor of Pauline Holden, as curatrix for Oscar Cooper, Jr., and Austin "Tyrone" Cooper, in the amounts of $516,299.75 (one-half of the amount of the medical bills) and $250,000.00 (one-half of the legal cap on general damages) for each son, with legal interest from July 2, 2004 (the date of the medical review panel request) at the rate of 6% per annum on the amount awarded until the date of judgment, and thereafter at the legal rate until paid. Subsequently, an order of remittitur was signed by the trial court, on October 7, 2011, granting the State a credit against the amount of medical expenses awarded (which totaled $1,032,599.50), based on a Medicaid write-off in the amount of $136,931.67, and, accordingly reducing each of Shirley Cooper's two sons' awards of $516,299.75 each to $447,833.91 each.
On November 4, 2011 the State filed an appeal of the trial court's October 7, 2011 reformed judgment, assigning the following errors: (1) the jury's verdict is unsupported by any evidence in the record that Shirley Cooper's death was caused by any action or inaction of Lallie Kemp six years earlier or by any evidence identifying what better outcome Ms. Cooper would have realized from the injuries, otherwise caused by her strokes, had Lallie Kemp medical personnel timely provided appropriate medical care, including the administration of anti-coagulant drugs; (2) the trial court erred in allowing the in globo introduction of medical expense records resulting from the defendant's alleged malpractice, without a foundation linking them to the actual medical costs and without reflecting medical expenses actually incurred and paid by Shirley Cooper or on her behalf; and (3) the trial court erred by failing to grant the State a remittitur for the total amount of the medical charges written off by providers of Medicaid-reimbursed and other gratuitous services.
On November 23, 2011 the plaintiff filed an answer to the appeal, seeking reversal of the remittitur and reinstatement of the original judgment on the jury's verdict and asserting on appeal that the trial court erred in granting a remittitur and giving the State a credit for Medicaid medical expenses that were written off, as the State: (1) did not, in answer or by pretrial order, plead entitlement to this credit or partial extinguishment of the debt, as required by LSA-C.C.P. art. 1005; (2) did not present at trial any evidence to identify or quantify such write-offs, as required by its burden of proof under LSA-C.C. art. 1831; (3) presented no such evidence in the five months after trial; (4) did not request an evidentiary hearing after trial to present Medicaid evidence until after judgment; (5) convinced the jury that almost $285,000 in bills should be excluded from the award; (6) failed to request jury interrogatories that would allow a determination of which hospitalizations the jury compensated and which were amongst the almost $285,000 in bills the jury disallowed in the award; and (7) obtained in the remittitur a redundant reduction of the total award for medical bills, by obtaining credit against some or all of almost $285,000 in bills that the jury did not award.
After a careful review of the voluminous record presented on appeal, we cannot conclude the jury was manifestly erroneous in its findings of fact, as the testimony and evidence presented at trial provided a reasonable factual basis for the findings, and the findings are not clearly wrong. See Stobart v. State, Department of Transportation and Development, 617 So.2d 880, 882 (La. 1993); Rosell v. ESCO, 549 So.2d 840, 844 (La. 1989); Mart v. Hill, 505 So.2d 1120, 1127 (La. 1987). Reasonable evaluations of credibility and reasonable inferences of fact should not be disturbed upon review, particularly where conflict exists in the testimony, as in the instant case. See Rosell v. ESCO, 549 So.2d at 844.
To establish a claim for medical malpractice, a plaintiff must prove, by a preponderance of the evidence: (1) the standard of care applicable to the defendant; (2) the defendant breached that standard of care; and (3) there was a causal connection between the breach and the resulting injury. Schultz v. Guoth, 2010-0343 (La. 1/19/11), 57 So.3d 1002, 1006-07 (citing LSA-R.S. 9:27943). To establish causation in a situation where the patient dies, the plaintiff need only prove that the defendant's malpractice resulted in the patient's loss of a chance of survival. The plaintiff is not required to shoulder the unreasonable burden of proving the patient would have survived if properly treated. The question of whether the malpractice contributed to the death (i.e., lessened the chance of survival) is a question of fact for the jury. Etcher v. Neumann, 2000-2282 (La. App. 1 Cir. 12/28/01), 806 So.2d 826, 837, writ denied, 2002-0905 (La. 5/31/02), 817 So.2d 105. In the instant case, the jury evaluated the medical testimony presented at trial and found that the actions or inactions of the State's medical personnel at Lallie Kemp caused the outcome of Ms. Cooper's stroke to be worsened and contributed (by a seventy-five percentage of comparative fault) to her death. Based on the entirety of the record, we are unable to say these findings are manifestly erroneous.4
Further, we are unable to say the jury abused its discretion in the amount of damages awarded. In the assessment of damages in cases of offenses, quasi offenses, and quasi contracts, much discretion must be left to the factfinder. See LSA-C.C. art. 2324.1. On appellate review, damage awards will be disturbed only when there has been a clear abuse of that discretion. The initial inquiry must always be directed at whether the trial court's award for the particular injuries and their effects upon this particular injured person is a clear abuse of the trier of fact's much discretion. Cole v. State, Department of Public Safety and Corrections, 2003-2269 (La. App. 1 Cir. 6/25/04), 886 So.2d 463, 465, writ denied, 2004-1836 (La. 10/29/04), 885 So.2d 589. The discretion vested in the trier of fact is "great," and even vast, so that an appellate court should rarely disturb an award of general damages. Reasonable persons frequently disagree about the measure of general damages in a particular case. It is only when the award is, in either direction, beyond that which a reasonable trier of fact could assess for the effects of the particular injury to the particular plaintiff under the particular circumstances that the appellate court should increase or reduce the award. Youn v. Maritime Overseas Corp., 623 So.2d 1257, 1261 (La. 1993), cert. denied, 510 U.S. 1114, 114 S.Ct. 1059, 127 L.Ed.2d 379 (1994). Only after making a finding that the record supports that the lower court abused its much discretion can the appellate court disturb the award, and then only to the extent of lowering it (or raising it) to the highest (or lowest) point which is reasonably within the discretion afforded that court. Coco v. Winston Industries, Inc., 341 So.2d 332, 335 (La. 1977).
In this case, the jury awarded $3,180,000 in general damages for Ms. Cooper's disability, loss of enjoyment of life, mental distress, and pain and suffering. Pursuant to LSA-R.S, 40:1299.39 (F), a judgment on this award was made in favor of Ms. Cooper's heirs in the total amount of $500,000.00 ($250,000.00 to each of her two sons). In addition, the jury awarded $1,032,599.50 in medical expenses, and, after a remittitur by the trial court (for the application of a credit for Medicaid medical expenses written-off), judgment was rendered for medical expenses in favor of Ms. Cooper's heirs in the total amount of $895,667.82 ($447,833.91 to each of her two sons). We find no abuse of discretion in the amount of damages for which the defendant was cast in judgment.
Furthermore, we find no error in the remittitur ordered by the trial judge, particularly in light of his reasons for the remittitur, which stated, in pertinent part:
In this jury trial medical expenses were submitted to the jury as an element of damages. The defendant objected insofar as the medical bills did not reflect the amount of the "write off on those bills paid by medicaid as required by [Bozeman v. State, 2003-1016 (La. 7/2/04), 879 So.2d 692]. It was obvious that the medical bills were an appropriate element of damages for the jury to consider, but neither party was prepared to delineate the amount of the medicaid write off So the court allowed the bills introduced into evidence, subject to the objection, and it was the understanding of the court if the jury returned a verdict favorable to the plaintiffs (and since the medicaid write off could not be granted plaintiff as a matter of law) the parties would ascertain that amount from the appropriate source and it would be deducted from the award prior to the judgment being signed.
A verdict was rendered in favor of the plaintiffs and an element of damages awarded was the medical bills submitted to the jury. In accordance with the court[]s understanding the parties were instructed to ascertain and submit to the court the amount of the medicaid write off In spite of repeated requests by the court months passed without the parties furnishing the amount of the medicaid write off. The court then signed a judgment in accord with the jur[y's] verdict and instructed the parties that any further matters would be handled with post judgment motions.
The defendants filed a post judgment motion for a judgment not withstanding verdict, a new trial, and alternatively, a remittitur. The court set a hearing on the motions for September 16, 2011.
At the hearing the court denied the [JNOV], and denied the motion for a new trial with the exception that the court determined that a partial new trial would be appropriate on the question of quantum with reference to the medicaid write off which the court determined to be easily separable from the remainder [of] the litigation. The court instructed that a partial new trial would be granted or alternatively a remittitur if plaintiff consented thereto. Plaintiff consented to a remittitur reserving any appeal rights. The court requested the parties do the following: 1) Use only the exhibit that reflected the bills introduced in evidence at trial and considered by the jury; 2) Determine which of those bills had been paid solely by medicaid; 3) On those bills paid only by medicaid subtract the amount paid by medicaid from the amount of the bill submitted; 4) The difference between the amount billed and the amount paid by medicaid would [be] added and the total would be the amount of the medicaid write off. That amount would be subtracted from the jury award of medical expenses as a remittitur.
The parties again professed that they were not prepared to furnish the desired information to the court. Accordingly, the court granted an additional ten days for the [p]arties to submit the requested figures. The parties agree to [$] 136,931.67. The disagreement is where medicaid paid nothing or paid in conjunction with medicare where a write down already occurred, Evidence would be necessary to determine what would be appropriate and that cannot be taken at this time.
The trial judge's reasons in this case show that he deducted only Medicaid expenses that had been written off from the amount of medical expenses awarded Where a plaintiff pays no enrollment fee, has no wages deducted, and otherwise provides no consideration for collateral source benefits received, as stated by the supreme court in Bozeman, that plaintiff may not recover "write-off amounts, as such a recovery would be a windfall. The Bozeman court concluded that Medicaid is a free medical service, as Medicaid patients pay no consideration for such benefits; therefore, since a Medicaid patient's patrimony has not been diminished with respect to medical expenses covered by Medicaid, Medicaid expenses that have been written off are not recoverable by a plaintiff (noting that this principle is not applicable to plaintiffs who receive Medicare or private insurance benefits, for which some premium has been paid). See Bozeman v. State, 879 So.2d at 705-06. See also Finister v. State DGTD, 2004-0194 (La. 11/24/04), 888 So.2d 214 (stating that the plaintiff is entitled to recover only the amount actually paid by Medicaid). Accordingly, we find no error in the remittitur in this case.5
For the reasons assigned, we affirm the trial court judgment, with each party to bear its own costs of this appeal. In accordance with LSA-R.S. 13.5112(A), the appellate costs to be paid by the State of Louisiana amount to $17,183.32.
AFFIRMED.
