loss of vision, loss of a limb or organ, the reduced enjoyment of life due to a disability or loss of a loved one, severe pain and emotional distress. punitive damages are not available in all states and, when allowed, are usually only awarded in the event of wanton and reckless conduct. statute of limitations there is only a limited time during which a medical malpractice lawsuit can be filed. in the united states, these time limits are set by statute. in civil law systems, similar provisions are usually part of the civil code or criminal code and are often known collectively as "periods of prescription" or "prescriptive periods." the length of the time period and when that period begins vary per jurisdiction and type of malpractice. therefore, each state has different time limits set. for example, in pennsylvania, there is a two-year statute of limitation, but in other states the limitations period may be longer. most states have special provisions for minors that may potentially extend the statute of limitations for a minor who has been injured as the result of medical malpractice. nature of malpractice and compensation further information: medical error a 2011 study in the new england journal of medicine reported that 75% of physicians in "low-risk" specialties and virtually 100% of physicians in "high-risk" specialties could expect to face a malpractice claim during their careers. however, the authors also noted that the vast majority of malpractice claims did not lead to any indemnity payments. most (73%) settled malpractice claims involve medical error. a 2006 study concluded that claims without evidence of error "are not uncommon, but most are denied compensation. the vast majority of expenditures go toward litigation over errors and payment of them. the overhead costs of malpractice litigation are exorbitant." physicians examined the records of 1452 closed malpractice claims. ninety-seven percent were associated with injury; of them, 73% got compensation. three percent of the claims were not associated with injuries; of them, 16% got compensation. 63% were associated with errors; of them, 73% got compensation (average $521,560). thirty-seven percent were not associated with errors; of them, 28% got compensation (average $313,205). claims not associated with errors accounted for 13 to 16% percent of the total costs. for every dollar spent on compensation, 54 cents went to administrative expenses (including lawyers, experts, and courts). claims involving errors accounted for 78 percent of administrative costs. a 2004 study of medical malpractice claims in the united states examining primary care malpractice found that though incidence of negligence in hospitals produced a greater proportion of severe outcomes, the total number of errors and deaths due to errors were greater for outpatient settings. no single medical condition was associated with more than five percent of all negligence claims, and one-third of all claims were the result of misdiagnosis. male doctors have nearly two and half times increased odds of having medico-legal action taken against them than female doctors, a result consistent across many years and found internationally. arguments about the medical liability system doctors' groups, patients, and insurance companies have criticized medical malpractice litigation as expensive, adversarial, unpredictable, and inefficient. they claim that the cost of medical malpractice litigation in the united states has steadily increased at almost 12 percent annually since 1975. more recent research from the same source has found that tort costs as a percentage of gdp dropped between 2001 and 2009, and are now at their lowest level since 1984. jury verdict research, a database of plaintiff and defense verdicts, says awards in medical liability cases increased 43 percent in 1999, from $700,000 to $1,000,000. however, more recent research from the u.s. department of justice has found that median medical malpractice awards in states range from $109,000 to $195,000. these critics assert that these rate increases are causing doctors to go out of business or move to states with more favorable tort systems. not everyone agrees, though, that medical malpractice lawsuits are solely causing these rate increases. a 2003 report from the general accounting office found multiple reasons for these rate increases, with medical malpractice lawsuits being the primary driver. despite noting multiple reasons for rate increases, the report goes on to state that the "gao found that losses on medical malpractice claims-which make up the largest part of insurers' costs-appear to be the primary driver of rate increases in the long run." more recent data has indicated that medical malpractice rates are generally no longer rising. in 2011, data pooled from the industry by the publication medical liability monitor indicated that medical malpractice insurance rates had declined for four straight years. the decrease was seen in both states that had enacted tort reform and in states that had not, leading actuaries familiar with the data to suggest that patient safety and risk management campaigns had had a more significant effect. major tort reform proposals include: special medical malpractice courts limits on noneconomic damages, and reduction of the statute of limitations for commencing a malpractice action. the majority of the american public supports reforms to the malpractice system. however, surveys show that the majority of the american public also vastly underestimate the extent of medical errors. recent research has shown that while both health consumers and health producers are concerned about some of the adverse consequences of healthcare litigation, health consumers perceive that increased healthcare litigation can reduce the incentives for negligence on the part of healthcare providers. at the same time, studies of these claims have found that there is no problem of increasing malpractice verdicts and insurance costs driving doctors out of business. nontraditional approaches to liability reform the traditional approach to liability reform is to limit the amount of damages that can be recovered by a plaintiff (as noted above). several new approaches to addressing medical malpractice have been investigated. communication and resolution programs: when a medical error is identified, the patient is approached by the physician and/or health care system and they mutually arrive at a settlement. several laws have been passed to facilitate communication and resolution (mandatory presuit notification laws, apology laws and state-facilitated dispute resolution laws). safe harbors for adherence to practice guidelines: this approach provides a defense for physicians if they follow pre approved clinical practice guidelines. judge-directed compensation: a group of judges with expertise in medical malpractice meet with each sides attorneys and negotiates a settlement between the parties. administrative compensation:sweden and new zealand created health courts. claims are sent to these courts that have the authority to settle a claim. attorneys are not required and the claims are settled based the opinions of neutral experts. compensation is awarded based on preset schedules and are based on the degree of injury. limits on recovery many jurisdictions placed non-economic damages caps that limit the amount that victims of medical malpractice can recover from negligent physicians, purportedly in an effort to decrease hospital and physician costs. in california, for example, recovery for non-economic damages are limited to $250,000. according to the supreme court of california, "noneconomic damages compensate the plaintiff for 'pain, suffering, inconvenience, physical impairment, disfigurement and other nonpecuniary damage .' section 1431.2, subdivision (b)(2) similarly defines noneconomic damages as 'subjective, non-monetary losses including, but not limited to, pain, suffering, inconvenience, mental suffering, emotional distress, loss of society and companionship, loss of consortium, injury to reputation and humiliation.'" tort reform supporters argue that states have enacted such laws in order to keep health care costs low, in addition to helping curb medical malpractice litigation. however, according to the supreme court of california, the state's non-economic damages caps are "not a legislative attempt to estimate the true damages suffered by plaintiffs, but rather an attempt to control and reduce medical malpractice insurance costs by placing a predictable, uniform limit on the defendant's liability for noneconomic damages." texas law creates the most difficult "hurdles" in the united states for a plaintiff to succeed in recovering damages for any medical malpractice, even for such objective cases such as an emergency room exposure to the ebola virus disease. texas law and effect texas passed a "tort reform" law taking effect on september 1, 2003. the act limited non-economic damages (e.g., damages for pain and suffering) in most malpractice cases to $250,000 across all healthcare providers and $250,000 for healthcare facilities, with a limit of two facilities per claim. as of 2013, texas was one of 31 states to cap non-economic damages. following 2003, medical malpractice insurance rates were reduced in texas. however, the center for justice & democracy at new york law school reports that rate reductions are likely attributable not to tort laws, but because of broader trends, such as "political pressure, the size of prior rate hikes, and the impact of the industry's economic cycle, causing rates to drop everywhere in the country." states which do not impose caps on malpractice damages, such as connecticut, pennsylvania, and washington, have experienced reductions or stabilization in malpractice rates as well. various studies have shown that the texas tort-reform law has had no effect on healthcare costs or the number of physicians practicing in the state. a february 2014 study found "no evidence to support" the claim that "there had been a dramatic increase in physicians moving to texas due to the improved liability climate." the study found that this is true "for all patient care physicians in texas, high-malpractice-risk specialties, primary care physicians, and rural physicians. plaintiffs' lawyers say that the texas law prevents patients from getting compensation or damages even in cases where the patient clearly deserves it. in particular, the "willful and wanton" negligence standard for emergency care, which requires that the harm to the patient be intentional, makes it impossible to win a case where the harm is clearly negligent but not willful. financial impact an august 2003 national bureau of economic research paper by katherine baicker and amitabh chandra found that (1) "increases in malpractice payments made on behalf of physicians do not seem to be the driving force behind increases in premiums"; (2) "increases in malpractice costs (both premiums overall and the subcomponent factors) do not seem to affect the overall size of the physician workforce, although they may deter marginal entry, increase marginal exit, and reduce the rural physician workforce"; and (3) "there is little evidence of increased use of many treatments in response to malpractice liability at the state level, although there may be some increase in screening procedures such as mammography." a 1996 study by daniel p. kessler and mark mcclellan analyzing data on elderly medicare beneficiaries treated for two serious cardiac diseases in 1984, 1987, and 1990 determined that "malpractice reforms that directly reduce provider liability pressure lead to reductions of 5 to 9 percent in medical expenditures without substantial effects on mortality or medical complications." a a 2004 congressional budget office (cbo) report using data from a private actuarial firm and the centers for medicare and medicaid services (cms) found that malpractice costs (excluding "defensive medicine") account for less than 2 percent of health care spending. a 2006 pricewaterhousecoopers report for america's health insurance plans (a health-insurer trade association) used the 2 percent figure and an extrapolation from the kessler and mcclellan report to estimate that the combined cost of insurance and defensive medicine accounts for 10 percent of total health care costs in the u.s. in 2009, the cbo "concluded that implementing a package of five malpractice reforms would reduce national health spending by about 0.5 percent." a study by michelle m. mello and others published in the journal health affairs in 2010 estimated that the total annual cost of the medical liability system, including "defensive medicine," was about 2.4 percent of total u.s. health care spending. the authors noted that "this is less than some imaginative estimates put forward in the health reform debate, and it represents a small fraction of total health care spending," although it was not "trivial" in absolute terms. a study by rand corp. researchers published in october 2014 in the new england journal of medicine concluded that laws restricting medical-malpractice suits do not reduce the amount of "defensive medicine" or reduce health-care costs. the researchers, led by daniel a. waxman, examined 3.8 million medicare patient records from hospital emergency departments from 1997 to 2011, comparing care in three states that enacted strict malpractice