Thomas v. Archer
2016 Alas. LEXIS 132, 384 P.3d 791, 2016 WL 7030289 (2016)
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Rule of Law:
A physician's fiduciary duty to a patient is limited to matters of medical expertise and does not extend to administrative tasks like obtaining insurance preauthorization. However, a physician's clear and definite promise to handle such administrative tasks may be enforceable under the doctrine of promissory estoppel if the patient foreseeably relies on that promise by forbearing from taking action themselves, resulting in substantial financial harm.
Facts:
- In October 2008, Rachel Thomas was admitted to the Ketchikan General Hospital emergency room for pregnancy-related complications.
- The attending physician, Dr. Sarah B. Archer, determined Thomas required an immediate medivac transfer to a better-equipped facility in Seattle.
- The Thomases informed Dr. Archer that they could not afford the medivac and needed preauthorization from their insurers, Ketchikan Indian Corporation Tribal Health Clinic (KIC) and Alaska Native Medical Center (ANMC).
- Dr. Archer allegedly promised the Thomases that she would contact KIC, that everything would be taken care of, and that if the insurer did not cover the costs, 'we' (understood as the hospital) would.
- Relying on Dr. Archer's alleged promise, the Thomases agreed to the medivac without contacting their insurers themselves.
- While arranging the transfer, Steven Thomas signed an 'Acknowledgment of Financial Responsibility,' which held him personally responsible for unpaid charges, though he listed KIC as the 'Payment Source.'
- The Thomases' insurers denied coverage for the over $92,000 in medical and transport bills, citing the failure to obtain preauthorization within the required timeframe.
Procedural Posture:
- Rachel and Steven Thomas filed a lawsuit against Dr. Sarah B. Archer and Ketchikan General Hospital in the Alaska superior court (the court of first instance).
- The superior court granted summary judgment to the hospital and Dr. Archer on the Thomases' claim for breach of fiduciary duty.
- The superior court later granted a second summary judgment motion in favor of the hospital and Dr. Archer, dismissing the remaining claims for breach of contract and promissory estoppel.
- The Thomases, as appellants, appealed the superior court's grants of summary judgment to the Supreme Court of Alaska.
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Issue:
Under the doctrine of promissory estoppel, is a physician's promise to obtain insurance preauthorization for a medically necessary procedure enforceable when the patients, in reliance on that promise, forbear from seeking preauthorization themselves, even if they would have undergone the procedure regardless of coverage?
Opinions:
Majority - Maassen, Justice
Yes, a physician's promise to obtain insurance preauthorization may be enforceable under promissory estoppel, as genuine issues of material fact exist regarding whether the patients' forbearance constitutes a substantial change of position. The court affirmed the dismissal of the fiduciary duty and contract claims but reversed the summary judgment on promissory estoppel. Reasoning: The court first held that a physician's fiduciary duty is confined to matters of medical expertise. Because obtaining insurance preauthorization is an administrative task, not a medical one, Dr. Archer's alleged promise fell outside the scope of her fiduciary duty. Second, the court found no enforceable contract because the essential element of consideration was missing. The Thomases had already decided to follow the medical advice and take the flight for health reasons, so their agreement to be transported was not a 'bargained-for' exchange for Dr. Archer's promise. However, the court found that the promissory estoppel claim should proceed to a jury. It reasoned that genuine issues of material fact existed for all four elements of promissory estoppel: (1) a jury could find the Thomases' failure to call their insurer themselves, in reliance on the promise, was a substantial change of position that led to their financial loss; (2) it was foreseeable that patients in a medical emergency would rely on such an assurance from their physician; (3) Dr. Archer's alleged promise was unconditional and could be found to be a clear, actual promise; and (4) determining whether enforcement is necessary in the interest of justice is a fact-intensive question unsuitable for summary judgment.
Analysis:
This decision clarifies the scope of a physician's fiduciary duty, strictly limiting it to medical matters and excluding administrative promises. Its primary significance, however, lies in its application of promissory estoppel in a healthcare context. The court establishes that a patient's reliance on a promise can be demonstrated through forbearance (failing to act) just as it can through an affirmative action. By distinguishing the decision to take the flight (medically necessary) from the decision not to call the insurer (reliance), the case provides a crucial pathway for holding healthcare providers accountable for administrative promises made in high-stakes, high-trust environments, even when a formal contract does not exist.
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