Linda Skelcy v. UnitedHealth Group Inc

NOT PRECEDENTIAL
UNITED STATES COURT OF APPEALS
FOR THE THIRD CIRCUIT
_____________
No. 15-1012
_____________
LINDA S. SKELCY,
Individually and as General
Administrator and Administrator ad
Prosequendum of the Estate of James T. Skelcy,
Appellant
v.
UNITEDHEALTH GROUP, INC;
OXFORD HEALTH INSURANCE, INC;
DENISE BEIGHE, M.D., individually and as an employee/agent
of Medical Evaluations Specialists, Inc.; MEDICAL EVALUATION
SPECIALISTS, INC.; DENNIS SANDOVAL, M.D., individually
and as an employee/agent of UnitedHealth Group; GAIL WILDER,
M.D., individually and as an employee/agent of UnitedHealth Group
_______________
On Appeal from the United States District Court
for the District of New Jersey
(D.C. No. 3-12-cv-01014)
District Judge: Hon. Anne E. Thompson
_______________
Submitted Under Third Circuit L.A.R. 34.1(a)
September 18, 2015
Before: FISHER, CHAGARES, and JORDAN, Circuit Judges.
(Filed: September 22, 2015)
_______________
OPINION
_______________
JORDAN, Circuit Judge.
Appellant Linda Skelcy, in her individual capacity and as the administratrix of the
estate of her husband, James Skelcy, asks us to reverse an order of the United States
District Court for the District of New Jersey dismissing her complaint against Medical
Evaluation Specialists, Inc. (“MES”) and Dr. Denise Beighe, M.D (“Dr. Beighe”).
Because we agree with the District Court that neither MES nor Dr. Beighe owed a duty of
care to Mr. Skelcy, we will affirm.
I. BACKGROUND
A. FACTUAL BACKGROUND1
In July of 2007, Mr. Skelcy was diagnosed with dermatomyositis, a connective
tissue disease. Later, he was diagnosed with interstitial lung disease (“ILD”), as a
secondary condition. At all relevant times, Mr. Skelcy was covered by a health insurance
policy issued by UnitedHealth Group, Inc. (“UnitedHealth”), by and through Oxford
Health Insurance, Inc. (“Oxford”).
Mr. Skelcy was first treated with various first-line medications, but they proved
ineffective. Then, in August 2009, his treating rheumatologist prescribed Rituximab

This disposition is not an opinion of the full court and, pursuant to I.O.P. 5.7,
does not constitute binding precedent.
1
We recount the facts as alleged by the non-movant, Mrs. Skelcy, accepting them
as true. Fowler v. UPMC Shadyside, 578 F.3d 203, 210 (3d Cir. 2009).
2
(“Rituxan”), a common next-step therapy. UnitedHealth and Oxford (collectively “the
UnitedHealth Defendants”) approved and covered Mr. Skelcy’s Rituxan treatments
without delay or question. Mr. Skelcy received two doses of the drug, to which he
responded very well. In fact, he responded so positively that he was able to maintain
remission of his dermatomyositis and ILD for almost one full year with those two doses
of Rituxan.
In July 2010, his symptoms returned. His treating rheumatologist immediately
prescribed another dose of Rituxan, which was scheduled to be administered later that
month. But, two days before the scheduled treatment, the UnitedHealth Defendants had
still not approved the dose of Rituxan. Mr. Skelcy’s treating rheumatologist therefore
faxed a letter of medical necessity to Oxford expressing Mr. Skelcy’s urgent need for a
dose of Rituxan or an intravenous immunoglobin (“IVIG”) infusion. The imminent need
for one of the treatments was or should have been immediately apparent to the
UnitedHealth Defendants, given Mr. Skelcy’s deteriorating condition and prior response
to Rituxan. Nevertheless, on the same day that they received the fax, the UnitedHealth
Defendants denied the claim for Rituxan or an IVIG infusion. Mr. Skelcy’s treating
rheumatologist had numerous follow-up conversations with the UnitedHealth
Defendants’ representatives in which he explained the need for treatment. He also
immediately responded by filing an “Expedited Utilization Review Appeal,” as permitted
by Mr. Skelcy’s insurance policy.
Within two days of receiving the clinical information necessary to process the
expedited appeal, the UnitedHealth Defendants transmitted the appeal to MES for a peer
3
review assessment. MES assigned Dr. Beighe, a rheumatologist located and licensed in
Arizona, to provide the peer review assessment of the expedited appeal.2 After
reviewing the materials provided by Mr. Skelcy’s treating rheumatologist, including
medical records indicating that Mr. Skelcy had previously responded well to Rituxan,
Dr. Beighe stated in her peer review assessment that, “[t]his type of therapy is not [the]
standard of care for this disease” and “[t]his specific therapy is not [the] standard of care
for this patient’s disease.” (App. at 49.) Dr. Beighe further specified that there was
inadequate medical literature to conclude that Rituxan was effective in treating
2
To determine whether the prescribed treatment was medically necessary for
Mr. Skelcy, Dr. Beighe was presented with seven questions upon which to base her
review:
1. Is this an FDA approved use of the requested medication(s)/service(s)?
2. Is this type of therapy “standard of care” for this disease/disease state?
3. Is this specific therapy “standard of care” for this patient’s disease/disease
state?
4. Is the clinical data from the prevailing peer-reviewed published medical
literature adequate to conclude that the requested medication(s)/service(s) is
effective in treating the member’s condition? [I]f no- please go to question
5.
5. Are there at least two articles in the peer-reviewed literature that show that
the proposed therapy is more likely to benefit the member than the standard
of care, or other available therapies?
6. Are alternative therapies possible?
7. Is there sufficient data for your opinion?
(App. at 128-29.) The questions do not require or even encourage the reviewing
physician to take a member’s specific condition, treatment history, or a treating
physician’s recommendations into account. Dr. Beighe was instead asked simply to
answer the non-specific, generic questions about the disease with which Mr. Skelcy was
afflicted.
4
Mr. Skelcy’s condition, but she also concluded that “IVIG would be [the] standard of
care at this point for the member.” (Id.)
The next day after receiving Dr. Beighe’s assessment, the UnitedHealth
Defendants again denied the request to treat Mr. Skelcy with Rituxan or an IVIG
infusion. In an internal memorandum, the UnitedHealth Defendants stated, “[a] board
certified rheumatologist has reviewed the request and has [determined] that the request
for Rituxan should be denied as unproved. The clinical data from the prevailing peer
reviewed published medical literature is not adequate to conclude that the requested
medication is effective in treating the member’s condition.” (App. at 50.) Despite
Dr. Beighe’s specific recommendation in favor of an IVIG infusion, the UnitedHealth
Defendants did not approve that therapy.
Approximately two weeks after the denial of Mr. Skelcy’s expedited appeal, his
treating rheumatologist faxed a letter to the UnitedHealth Defendants pleading that
Mr. Skelcy had received Rituxan in August 2009 “with excellent response,” and stating
that the “patient is a father, is a husband, and the main bread winner of his family” and
that “[a] further deterioration of his condition … is imminent.” (App. at 50-51.) On
August 9, 2010, thirty-two days after receiving Mr. Skelcy’s claim for treatment, the
UnitedHealth Defendants reversed their decision and approved the Rituxan treatment.
The record reveals no explanation for their tragically belated change of heart. Within 36
hours of the UnitedHealth Defendants’ decision to approve the Rituxan treatment,
Mr. Skelcy died. The Union County Medical Examiner’s Office determined that the
5
cause of death was chronic dermatomyositis, interstitial pulmonary fibrosis,
endomyocardial fibrosis, and cardiac arrhythmia.
B. PROCEDURAL HISTORY
Mrs. Skelcy filed her First Amended Complaint on April 13, 2012, asserting, inter
alia, claims for negligence and negligence per se against MES and Dr. Beighe. On June
29, 2012, MES and Dr. Beighe filed a motion to dismiss all claims against them,
advancing three arguments: (1) neither owed a duty of care to Mr. Skelcy; (2) the statute
underlying the negligence per se claims did not impose a duty upon them; and (3) the
court lacked personal jurisdiction over Dr. Beighe. Mrs. Skelcy responded by filing a
motion for leave to file a Second Amended Complaint, withdrawing the negligence per se
claims. She also opposed MES’s and Dr. Beighe’s motion to dismiss the negligence
claims.
The District Court granted MES’s and Dr. Beighe’s motion to dismiss, reasoning
that “there is both a lack of a demonstrable duty to Mr. Skelcy on the part of [MES or
Dr. Beighe] and of causation.” (Id. at 22.) The Court said that, because neither MES nor
Dr. Beighe had a special or contractual relationship with Mr. Skelcy, “there exists no
grounds for traditional medical malpractice [or negligence] claims against Dr. Beighe” or
MES. (Id.) Moreover, given that neither MES nor Dr. Beighe set the standard for review
in the UnitedHealth Defendants’ treatment approval process or made the final judgment
on treatment certification, the District Court found no “sufficient nexus between the
actions of [MES or Dr. Beighe] and Mr. Skelcy’s death.” (Id.) The District Court also
denied Mrs. Skelcy’s motion to amend her remaining claims against MES and
6
Dr. Beighe, stating that any motion to amend the remaining negligence claims would be
futile.3
The claims against the remaining defendants survived and the case proceeded
through discovery. It was ultimately closed on December 5, 2014, pursuant to a
settlement between Mrs. Skelcy and those defendants, thereby rendering the dismissal of
Mrs. Skelcy’s claims against MES and Dr. Beighe a final order subject to appeal. Mrs.
Skelcy then timely appealed.
II. DISCUSSION4
The District Court dismissed Mrs. Skelcy’s claims against MES and Dr. Beighe
because it found as a matter of law that neither defendant owed her a duty of care and
also that she failed to demonstrate that their negligence, if any, caused Mr. Skelcy’s
death. Because we agree that neither defendant owed Mr. Skelcy a duty of care, we do
not reach the second basis for the District Court’s ruling.
“The fundamental elements of a negligence claim are a duty of care owed by the
defendant to the plaintiff, a breach of that duty by the defendant, injury to the plaintiff
proximately caused by the breach, and damages.” Robinson v. Vivirito, 86 A.3d 119, 124
The District Court, having disposed of Mrs. Skelcy’s claims against MES and
3
Dr. Beighe on Rule 12(b)(6) grounds, did not address Dr. Beighe’s argument that she was
not subject to the Court’s personal jurisdiction.
4
The District Court had jurisdiction under 28 U.S.C. § 1332. We have appellate
jurisdiction under 28 U.S.C. § 1291. We exercise plenary review over a dismissal under
Rule 12(b)(6). Pearson v. Sec’y Dep’t of Corr., 775 F.3d 598, 601 (3d Cir. 2015). “To
survive a motion to dismiss, a complaint must contain sufficient factual matter, accepted
as true, to ‘state a claim to relief that is plausible on its face.’” Ashcroft v. Iqbal, 556
U.S. 662, 678 (2009) (quoting Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570 (2007)).
7
(N.J. 2014). The existence of a duty and the scope of that duty are generally questions of
law for the court to decide. Carvalho v. Toll Bros. & Developers, 675 A.2d 209, 212
(N.J. 1996). “[W]hether a duty exists is ultimately a question of fairness. The inquiry
involves a weighing of the relationship of the parties, the nature of the risk, and the public
interest in the proposed solution.” Reed v. Bojarski, 764 A.2d 433, 443 (N.J. 2001)
(internal quotation marks omitted). “A duty is said to arise out of the existence of a
relationship between the parties such that social policy justifies its imposition.” Id.
(internal quotation marks omitted). Whether a physician owes any duty to an individual
who is the subject of a peer review assessment as part of that individual’s claim for health
insurance coverage is a question that has not been addressed by the New Jersey Supreme
Court. We must therefore “predict how the New Jersey Supreme Court would rule if
presented with this case.” Repola v. Morbark Indus., Inc., 934 F.2d 483, 489 (3d Cir.
1991).
Mrs. Skelcy relies on a small set of cases to argue that, “under New Jersey law, no
traditional doctor-patient relationship or special duty is required to maintain a cause of
action for negligence against a physician … .” (Opening Br. at 14.) She asserts that,
given the broad duty of care imposed upon physicians under New Jersey law, MES and
Dr. Beighe owed her husband a duty of care, even though no privity or doctor-patient
relationship bound him to them.
The first case presented as support is Beadling v. Sirotta, 197 A.2d 857 (N.J.
1964). George Beadling had applied for a job as a machinist. His would-be employer
scheduled a pre-employment physical, which included a chest x-ray. Dr. Sirotta, the
8
radiologist who examined Beadling’s x-ray, detected a lung abnormality that he believed
was evidence of active tuberculosis. Dr. Sirotta told Beadling that something was
generally amiss with the x-ray, but he did not reveal any details of the condition to
Beadling. Instead, Dr. Sirotta disclosed those details to the would-be employer who
decided not to hire Beadling. Dr. Sirotta did, however, subsequently communicate with
Beadling’s treating physicians, who were able to resolve the illness. Nevertheless, after
undergoing a series of tests at the hospital and six weeks’ home confinement, Beadling
sued numerous parties, including Dr. Sirotta who had failed to immediately inform him
of his malady. Dr. Sirotta defended on the ground that he had no physician-patient
relationship with Beadling, and, therefore, no corresponding duty. The Supreme Court of
New Jersey rejected Dr. Sirotta’s absolute claim that the absence of a physician-patient
relationship forecloses the existence of any duty, stating, “[w]hether or not a physician-
patient relationship exists, … a physician in the exercise of his profession examining a
person at the request of an employer owes that person a duty of reasonable care.” Id. at
860. But the Beadling court did not define the scope of a physician’s duty of reasonable
care to an examinee because, “even assuming a duty was owed to [Beadling] to examine
and report with reasonable care,” the court found “no evidence of its breach” since Dr.
Sirotta’s post-examination communications had been instrumental in helping Beadling’s
treating physicians head off the tuberculosis. Id. at 861.
Mrs. Skelcy next relies on Ranier v. Frieman, 682 A.2d 1220 (N.J. Super. Ct.
App. Div. 1996). The plaintiff in that case, Penice Ranier, claimed that his ability to
work had been compromised by deteriorating vision, so he applied for social security
9
disability benefits. In July 1992, the Department of Labor referred Ranier to
Dr. Frieman, a board-certified ophthalmologist. Dr. Frieman examined Ranier and, in his
report, described the examination as a “normal ocular examination,” diagnosed myopia
(nearsightedness) and presbyopia (farsightedness), and opined that there was a possibility
of malingering. Id. at 1221. Based on Dr. Frieman’s report, the disability claim was
rejected. A few months later, Ranier’s vision problems persisted. After visiting his own
ophthalmologist, a brain tumor was discovered in his optic chiasm, which was the cause
of his declining eyesight. Ranier sued Frieman, claiming that he had negligently failed to
find the tumor. Frieman moved for summary judgment. He argued that, since he was
retained by the Department of Labor to examine Ranier on its behalf and to report only to
it, there was never a physician-patient relationship between him and Ranier, and, thus, he
owed no duty to Ranier to render a professionally reasonable diagnosis. The New Jersey
Superior Court rejected Dr. Frieman’s argument. Relying on Beadling, the Ranier court
recognized that “a professional’s duty of care is owed not only to his patient or client but
also to those third parties who will foreseeably and reasonably rely on his skill and care
in the performance of a particular professional undertaking.” Id. at 1223. And, on the
facts presented, the Ranier court concluded that, because Ranier had “relied, both
reasonably and foreseeably, on the examining physician’s diagnosis,” Dr. Frieman had a
duty, “as a matter of fairness,” to Rainier as well as to the Department of Labor to make a
professionally reasonable and competent diagnosis. Id.
Finally, Mrs. Skelcy buttresses her argument that New Jersey law would impose a
duty of care on MES and Dr. Beighe by relying upon Reed v. Bojarski, 764 A.2d 433
10
(N.J. 2001). Like Beadling and Ranier, Reed called upon a New Jersey court to further
define the boundaries of the duty of care that a physician owes to an examinee. In that
case, the decedent, Arnold Reed, underwent a pre-employment physical examination.
The would-be employer had contracted with Environmental Medicine Resources, Inc.
(“EMR”) to perform the examination. EMR subcontracted with Life Care Institute, Inc.
(“Life Care”) to perform physicals and medical imaging services, including evaluations
of pre-employment x-rays. Dr. Bojarski, an employee of Life Care, conducted Reed’s
physical. A radiologist who examined Reed’s chest x-ray told Dr. Bojarski that Reed had
a widened mediasternum, which may be an indicator of lymphoma, including Hodgkin’s
disease. Dr. Bojarski subsequently sent the x-ray, along with the rest of Reed’s
examination package to EMR. Reed stated in his report to EMR that the x-ray was
“abnormal,” but he made no reference to the widened mediasternum. Two days after
Dr. Bojarski sent his report to EMR, the radiologist gave Dr. Bojarski a written report on
Reed’s x-ray, recommending a follow-up CT scan, but Dr. Bojarski never conveyed that
suggestion or the report to EMR. About six months later, Reed was admitted to the
hospital and, after a chest x-ray showed a large mass in his mediasternum, he was
diagnosed with Stage IIB Hodgkin’s disease. He died eight months later. Reed’s widow
sued Dr. Bojarski and Life Care. At trial, the judge instructed the jurors that, if they
found that it was reasonable for Dr. Bojarski to forward the materials concerning Reed to
EMR and rely on EMR’s contractual obligation to independently review the materials
and inform Reed of any adverse findings, then they could not find Dr. Bojarski negligent.
With that instruction, the jury unanimously found for Dr. Bojarski. The New Jersey
11
Supreme Court reversed. It held that, while a pre-employment examination does not
establish a traditional physician-patient relationship, the examination still creates a
relationship “in which a physician is expected to exercise reasonable care commensurate
with his expertise and training, both in conducting the examination and in communicating
the results to the examinee.” Id. at 443. That is so, the court explained, because “the
patient is entitled to rely on the physician to tell him of a potential serious illness if it is
discovered. Any reasonable person would expect that and the duty to communicate with
a patient who is found to be ill is non-delegable.” Id.
Relying on those cases,5 Mrs. Skelcy argues that MES and Dr. Beighe owed her
husband a duty of care. In fact, she says, “[t]his matter presents a more compelling
5
Mrs. Skelcy also briefly cites a somewhat related collection of cases in which
New Jersey courts have held a professional liable to non-client third parties who
reasonably and foreseeably relied on the professional’s skill and care in the performance
of a professional undertaking. See Snyder v. Am. Ass’n of Blood Banks, 676 A.2d 1036,
1054 (N.J. 1996) (holding that the American Association of Blood Banks owes a duty of
ordinary care to persons receiving blood or blood products from its members, including
the plaintiff who had no direct contact with the defendant but who contracted AIDS from
a tainted unit of blood collected by one of its members); Petrillo v. Bachenberg, 655 A.2d
1354, 1361-62 (N.J. 1995) (holding that an attorney for a seller of real estate has a duty
not to provide misleading information to potential buyers who the attorney knows, or
should know, will rely on that information); Carter Lincoln-Mercury, Inc., Leasing Div.
v. EMAR Grp., Inc., 638 A.2d 1288, 1297-99 (N.J. 1994) (holding that an insurance
broker engaged to obtain insurance on behalf of a prospective insured owes a duty to a
loss-payee subsequently named on the acquired policy to place the insurance with a
financially stable insurance carrier); H. Rosenblum, Inc. v. Adler, 461 A.2d 138, 154 (N.J.
1983) (holding the auditor of a corporation liable to all those whom the auditor should
reasonably foresee as recipients from the audited company of its financial statements for
its proper business purposes, provided that the recipients rely on the statements pursuant
to those business purposes), superseded by statute, N.J. Stat. Ann. 2A:53A-25, as
recognized in Cast Art. Indus., LLC v. KPMG, LLP, 36 A.3d 1049 (N.J. 2012); Safer v.
Estate of Pack, 677 A.2d 1188, 1192 (N.J. Super. Ct. App. Div. 1996) (holding that a
12
context to impose a duty of reasonable care upon a physician, than the pre-employment
examination context of Reed, Beadling and Ranier.” (Opening Br. at 19). In those cases,
the purpose of the physician’s examination was not to affect medical treatment but to
determine fitness for employment. Here, she argues, MES and Dr. Beighe were
delegated a much weightier responsibility – reviewing and influencing whether a patient
would have coverage for treatment or a procedure, potentially preempting a treating
physician’s opinions and interfering with patient care. Mrs. Skelcy contends that often
only a physician in Dr. Beighe’s position will have the requisite expertise to perform an
independent review to decide the ultimate outcome of an insurance claim. And, she
continues, the peer review that Dr. Beighe undertook caused the arbitrary denial of a
proven treatment for Mr. Skelcy’s deteriorating condition, which was a substantial factor
in causing his death. According to Mrs. Skelcy, “[a]bsent the imposition of a duty upon
the reviewing physician in this context, arbitrary coverage decisions will no doubt
continue to result in the grave consequences underlying the current matter.” (Opening
Br. at 22.) Therefore, she says, the public policy principles inherent in analogous New
Jersey cases strongly suggest that a duty should be imposed on MES and Dr. Beighe in
this case. Furthermore, she points out, unlike the pre-employment examinees, “Mr.
Skelcy pa[id] premiums in exchange for coverage of medically necessary treatments with
the expectation that treatment would not be arbitrarily withheld.” (Id. at 20.)
physician has a duty to warn a patient’s immediate family members of avoidable harm
from genetically transmissible diseases).
13
We sympathize with Mrs. Skelcy and share the sense of injustice prompted by the
UnitedHealth Defendants’ decision to delay her husband’s treatment until it was too late
to save his life. That does not mean, however, that, under New Jersey law, either MES or
Dr. Beighe owed a duty of care to her husband.6 The cases cited by Mrs. Skelcy
demonstrate how New Jersey courts have liberally, but not heedlessly, extended remedies
to non-patients injured by the actions or inaction of physicians. Mrs. Skelcy is correct
that a traditional doctor-patient relationship or special duty is not required to maintain a
cause of action for negligence against a physician in New Jersey, but we think she is
likely wrong that New Jersey courts would impose a duty on facts such as the ones here.
There is a clear and common thread running through Beadling, Ranier, and Reed that is
absent here – each of those cases involved personal interactions with or affirmative acts
by a physician that induced the injured party to foreseeably and reasonably rely on the
physician to discover or disclose serious illnesses. While none of those cases found that a
physician-patient relationship existed, they each relied upon the existence of some
“relationship between the parties” that could be inferred from the parties’ interactions and
that entitled the injured party to rely on the physician’s competency. Reed, 764 A.2d at
443 (internal quotation marks omitted).
The facts of this case are different in at least two significant ways. First,
Mr. Skelcy had absolutely no interaction of any kind with Dr. Beighe. In fact, he
apparently had no awareness that Dr. Beighe even existed, let alone that she was
6
Our holding is strictly limited to the claims contained in Mrs. Skelcy’s
complaint. We do not opine whether entities and physicians could be liable as aiders and
abettors in a scheme designed to deny insurance claims in bad faith.
14
performing services connected to his insurance claim. All Dr. Beighe did in connection
with Mr. Skelcy’s case was to review medical records and answer questions posed by the
UnitedHealth Defendants. That difference undermines Mrs. Skelcy’s claims against
MES and Dr. Beighe, since Reed was clear that the “non-delegable duty” of care owed by
a physician stems from the trust a patient places in the doctor after a relationship arises
through personal interactions, in that case a physical examination. Id.; see also Nolan v.
First Colony Life Ins. Co., 784 A.2d 81, 86 (N.J. Super. Ct. App. Div. 2001) (holding that
Reed’s reasoning has little purchase in a “commercial setting” where a healthcare
professional reviewed a plaintiff’s blood test results but did not form a relationship of
“trust or reliance” with the injured party). Second, even assuming that Mr. Skelcy relied
on Dr. Beighe’s professional competence, which he did not, it was not the sort of reliance
that New Jersey courts have protected in the past. In Beadling, Ranier, and Reed, New
Jersey courts protected a person’s ability to safely rely on a physician’s implied or
express representations when making medical decisions, such as selecting an appropriate
course of treatment. But the reliance interest claimed here is completely distinct.
Mr. Skelcy did not rely on Dr. Beighe to help him understand his physical condition or
determine an appropriate course of treatment; if he had relied on Dr. Beighe at all, it was
to help him get reimbursed for his desired course of treatment.
We thus doubt that the New Jersey Supreme Court would recognize a duty of care
on these terribly sad facts.
15
III. CONCLUSION
For the foregoing reasons, we will affirm the District Court’s dismissal of the
claims against MES and Dr. Beighe.
16