## Facts

- In October 2008, Rachel Thomas went to the emergency room at Ketchikan General Hospital with pregnancy-related complications.
- Dr. Sarah Archer evaluated Rachel and concluded she was at risk of premature delivery and needed an immediate transfer by air ambulance (medivac) to a better-equipped facility.
- Because weather prevented transfer to Anchorage, Dr. Archer recommended medivac transport to Swedish Medical Center in Seattle.
- Rachel and her husband, Steven Thomas, told Dr. Archer they could not afford the medivac and believed their Alaska Native/tribal coverage required preauthorization from the Ketchikan Indian Corporation Tribal Health Clinic (KIC) and the Alaska Native Medical Center (ANMC).
- The Thomases alleged Dr. Archer said she would contact KIC, told them not to worry because everything would be taken care of, and stated that if KIC did not cover the transport, “we” would (which the Thomases understood to mean the hospital/medical provider would pay).
- Steven signed an “Acknowledgment of Financial Responsibility” identifying KIC as the payment source but also stating he accepted personal responsibility for unpaid charges and agreed to hold the hospital harmless.
- Rachel was transported to Seattle and treated there.
- Dr. Archer did not contact KIC/ANMC about authorization until many months later (more than six months after the transfer), and coverage was denied.
- The Thomases received large bills, including charges from the medivac provider (Guardian Flight) and Swedish Medical Center, totaling more than $90,000.
- The Thomases sued Dr. Archer and her affiliated medical practice (PeaceHealth Medical Group d/b/a Ketchikan OB/GYN) for breach of fiduciary duty, breach of contract, promissory estoppel, and negligent or intentional infliction of emotional distress.
- The emotional-distress claims were dismissed/withdrawn, and the superior court granted summary judgment to defendants on fiduciary duty, contract, and promissory estoppel.
- The superior court also awarded attorney’s fees and costs after reviewing detailed billing records in camera, without providing the Thomases access to the itemized records.
- The Thomases appealed the summary-judgment rulings and the fee award.

## Issues

1. Whether a physician’s fiduciary duty to a patient extends beyond medical treatment decisions to obtaining insurance preauthorization or protecting the patient from uncovered medical bills.
2. Whether Dr. Archer’s alleged statements about contacting insurers and paying if coverage was denied created an enforceable oral contract supported by consideration.
3. Whether, even without a contract, the alleged assurance could be enforced under promissory estoppel based on reasonable, foreseeable, and detrimental reliance.
4. Whether the superior court’s attorney-fee procedure violated due process by relying on ex parte, in camera review of detailed billing records not disclosed to the Thomases.

## Decision

- Affirmed summary judgment for defendants on breach of fiduciary duty.
- Affirmed summary judgment for defendants on breach of contract.
- Reversed summary judgment on promissory estoppel and remanded for further proceedings.
- Vacated the attorney’s fee award and remanded for reconsideration using procedures that provide a meaningful opportunity to respond while still protecting privileged material as needed.

## Legal Principles

- A physician–patient relationship is fiduciary in nature as to medical treatment and advice; it does not, without more, create a fiduciary obligation to secure insurance authorization or guarantee payment for care.
- An enforceable contract requires consideration; a patient’s acceptance of urgently recommended medical care is not, by itself, a bargained-for exchange supporting a separate promise to pay or obtain coverage.
- Promissory estoppel may allow enforcement of a promise when the promisor should reasonably expect reliance, the promisee in fact relies, the reliance is substantial, and enforcement is necessary to avoid injustice; disputed facts about the existence and meaning of the promise and the reasonableness of reliance can defeat summary judgment.
- Fee awards must be made through procedures consistent with due process; while courts may use in camera review to protect privileged communications, the opposing party must still have a meaningful chance to challenge the request.

## Conclusion

The Alaska Supreme Court held that Dr. Archer’s fiduciary duty to the Thomases was confined to the medical relationship and that the alleged assurances did not form an enforceable contract because there was no consideration, but it ruled that a jury could find a definite promise and reasonable, detrimental reliance sufficient for promissory estoppel and therefore reinstated that claim; the court also vacated the attorney-fee award because the in camera, non-disclosed billing review did not give the Thomases an adequate opportunity to contest the fees and required reconsideration on remand.


Thomas v. Archer, 384 P.3d 791 (2016)